ective date: 31/08/16

Australian Fire Service Medal (AFSM) Nomination

Part One – Nominee details

Surname:       First names:      

Payroll/Volunteer ID No.:       Rank/position:      

Region: Please select: Date of birth:       Work location:      

Home address:       Postcode:      

Phone:       Email:      

Previous awards received (include award name and year awarded):1.      2.      3.      

Part Two – Nominating officer details

Name:       Position:      

Location:       Region: Please select:

Email:      

Part Three – Nomination statement

Detail how the nominee has provided distinguished service as per award criteria:

     

Part Four – Endorsement by nominating officer

I endorse this nomination and have attached three reference statements to support this nomination.

Signed: Date:      

Queensland Fire and Emergency Services is collecting personal information for the purpose of processing nominations subject to the requirements of the Information Privacy Act 2009 (the IP Act) which are defined in the 11 Information Privacy Principles (IPPs). For information on the 11 IPPs, refer to Schedule 3 of the IP Act.

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