national emergency medal · the national emergency medal was established by her majesty, the queen...
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The National Emergency Medal was established by Her Majesty, The Queen for the purpose of accordingrecognition for the unique contribution and significant commitment of those persons who have provided service in response to a nationally-significant emergency.
National Emergency Medal
NOMINATION FORM SIGNIFICANT SERVICE
The Committee in considering significant service nominations will determine, in accordance with the National Emergency Medal Regulations 2011 whether the nominee’s contribution:
The Governor-General may approve an award for significant service, on the recommendation of the Committee.
Clasp for Victorian Bushfires 2009 will be “VIC FIRES 09”; and
Significant service nominations upon receipt are researched and prepared by the Australian Honours and Awards Secretariat for presentation to the Committee.
In preparing a nomination the Committee requires a detailed account of the nominee’s service and referee statements, particularly addressing how the service could be considered extraordinary.
The Medal may be awarded for: sustained service recognising those who contributed in direct response and meet the criteria determined for each declared emergency; or
significant service recognising those that performed extraordinarily during the declared emergencies, and do not satisfy criteria for sustained service.
As part of the National Emergency Medal Regulations 2011, the bushfires that happened in the State of Victoria in February 2009, the floods that happened in the State of Queensland during December 2010 and January 2011 and Cyclone Yasi have been declared as nationally-significant emergencies.
The National Emergency Medal Committee at its meeting in December 2011 determined that the:
Queensland Floods and Cyclone Yasi should be combined for the purpose of the Medal and the Clasp “QLD 2010-11” awarded;
sustained service criteria for each clasp.
For further information please refer to the National Emergency Medal Regulations 2011 which can be found at www.gg.gov.au.
was part of the response efforts to the nationally-significant emergency;assisted with the protection of lives and property;was extraordinary.
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DETAILS OF THE NOMINEE
* Title/Rank (Mr,Mrs, Ms, Dr, Prof,etc.)
* Given Names
* Postal Address
Position/Title
Home Phone Number
Business Phone Number
* Date of Birth (e.g. 0 1 / 11/ 1956)
* Surname
Organisation/ Business Name
State Postcode
Mobile Phone Number
Email Address
SECTION
1
2016/2
Suburb
State PostcodeSuburb
to
to
to
to
Queensland Floods 2010-11 and Cyclone Yasi
Days:
Days:
Days:
Days:
Deceased: No Yes
Please ensure that all sections marked with an asterisk (*) are completed.
to Days:
to
to
Days:
Period 2
Period 4
Period 5
Period 6
Period 7
Period 8
Period 3
Days:
Emergency the nominee rendered significant service for:
Victorian Bushfires 2009
Paid/Unpaid:to Days:
Dates of service:
Paid/Unpaid:
Paid/Unpaid:
Paid/Unpaid:
Paid/Unpaid:
Paid/Unpaid:
Paid/Unpaid:
Paid/Unpaid:
Total Days:
(see Section 2 to provide details of service for these periods)
Service/Employee Number
Organisation/BusinessAddress
*
*
Period 1
SECTION
2
NOTE : If there is insufficient space, you may provide additional information on the f ollowing page or on separate sheets and attach them to the nomination form.
DETAILS OF SERVICE RENDERED BY THE NOMINEE Detail the service undertaken by the nominee, including the location, and relate this to the periods of service identified in Section 1.
The Committee will consider whether the nominee's service:
was part of the response efforts to the nationally-significant emergency; assisted with protecting lives or property;was extraordinary.
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SECTION
2DETAILS OF SERVICE RENDERED BY THE NOMINEE
CONTINUED
3DETAILS OF REFEREES WHO ARE ABLE TO VERIFY THE CONTRIBUTION/SERVICE OF THE PERSON YOU ARE NOMINATING
SECTION
Postal Address
Position/Title
Home Phone Number
Business Phone Number
Organisation/ Business Name
State Postcode
Mobile Phone Number
Email Address
Suburb
State PostcodeSuburb
Given Names
Title/Rank (Mr, Mrs, Ms, Dr, Prof, etc.)
Surname
Postal Address
Position/Title
Home Phone Number
Business Phone Number
Organisation/ Business Name
State Postcode
Mobile Phone Number
Email Address
Suburb
State PostcodeSuburb
Given Names
Title/Rank (Mr, Mrs, Ms, Dr, Prof, etc.)
Surname
NOTE : If there is insufficient space, you may provide additional referee details on separate sheets and attach them to the nomination form.
Relationship to nominee
Relationship to nominee
Organisation/BusinessAddress
Organisation/BusinessAddress
SECTION
4DETAILS OF PERSON SUBMITTING NOMINATION Please provide your contact details to enable officers of the Australian Honours and Awards Secretariat, Government House, Canberra to seek further details, if required.
Organisation/ Business Name
Mobile Phone Number
Email Address
Title/Rank (Mr, Mrs, Ms, Dr, Prof, etc.)
Given Names
Postal Address
Position/Title
Home Phone Number
Surname
State PostcodeSuburb
Business Phone Number
More information or help If you have any further questions, or require guidance in the preparation of the nomination, please call the Australian Honours and Awards Secretariat, Government House, Canberra on telephone (02) 6283 3604.
For further information please refer to the National Emergency Medal Regulations 2011 which can be found at www.gg.gov.au.
Describe your relationship to the nomineeeg. self/employer/spouse
Checking this box forms your signature and confirms that all information provided on this form is accurate and true to the best of your knowledge. We may contact your organisation or others to confirm the information you have provided.
Declaration
Please note:If the above link does not work, please send the completed nomination form to [email protected]