Australian Honours Nomination Form

About the Service Awards

The Australian Police Medal (APM), the Australian Fire Service Medal (AFSM), and the Emergency Services Medal (ESM) are meritorious Service Awards. The APM, AFSM and ESM were established to recognise distinguished service. The Governor-General awards these honours upon recommendation of the responsible Commonwealth, state and territory ministers.

Nominations are to be made ‘in-confidence’ and should address the criterion for the award, which requires the nominee to have displayed ‘distinguished service’. Nominees should not be made aware of their nomination. A nomination does not necessarily infer acceptance through the system.

Nominee details

Name

DOB

Service area

Date commenced

Length of service

Rank & Current position

Work location

Telephone

Australian citizen

Nominator details

Name

Rank/Designation

Work Unit

Work Location

Telephone

Nomination statement

A nomination statement is required to assist the selection panel to assess the nominations. The nomination statement must contain comprehensive information on the distinguished service or achievement for which the nomination is being made.

Please provide sufficient information to justify the nomination based on outstanding or distinguished service and taking into account the nominee’s service, awards, qualifications, community involvement, special investigations, projects or performance. A list of positions held over the years is not sufficient.

List previous operational/frontline roles the nominee has held in the organisation. Include description, dates and length of service.

Describe the operational/frontline service that the nominee is currently undertaking / or has recently undertaken, which makes the nominee eligible for this award.

Details of any significant or outstanding contribution the nominee has made to your organisation. This may include, but is not limited to: Specific details of prolonged exposure to hazard or demonstration of exceptional skills in one or more emergency incidents; Significant deployments in emergency situations; and/or Implementation and facilitation of programs or innovations that directly supports and provides enduring benefit for frontline personnel.

Nominees direct supervisor details

Name and title

Nominees line manager details

Name and title

Referee1

Name

Rank/Designation

Telephone

Work Location

Referee1 statement

Maximum 2 files.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Referee2

Name

Rank/Designation

Telephone

Work Location

Referee2 statement

Acknowledgement and Signature

By submitting this form, I acknowledge that I have declared any association with the nominee which would be or perceived to be a conflict.

Nominator signature

Sign above

Date