Remote Service Ribbon for Retired or Resigned Members Application Form

The Northern Territory Police Force (NTPF) Remote Service Ribbon may be awarded to recognise retired or resigned members who completed two years continuous service in areas that are specifically gazetted as remote or track stations.

Details of Applicant

Family Name

Given Name(s)

Telephone

Date of Birth

Home Address

Postal Address

Details of Service

Commencement Date

Separation Date

Rank/Designation

Registered Number

Squad Number

Please note: If your retirement or resignation occurred prior to 01/01/1994, proof of service is required, e.g. Letters and Certificates of Service. In addition a statutory declaration form confirming details and periods of remote service must be submitted with this application. Northern Territory statutory declaration information and forms can be located via https://nt.gov.au/law/processes/statutory-declarations.

Remote Service Details

Remote Station/s	Approximate Start Date	Approximate End Date	Operations
Remote Station/s	Approximate Start Date	Approximate End Date

Details of the person making application if not applicant (Executor, Administrator or Next of Kin)

Family Name

Given Name(s)

Telephone

Date of Birth

Home Address

Postal Address

Declaration by Applicant

Please ensure that prior to submitting this application the following required documentation is attached:

Documents containing proof of service (Letters or Certificates of Service)
Statutory declaration form confirming details and periods of remote service, if retirement date is before 01/01/1994.
If applicable; proof that you are an Executor of the will, Administrator in case of intestacy, Power of Attorney, or a person who can prove legal status as a beneficiary to tghis claim.

Applicant's name

Signature

Sign above

Date

Attachments (if any)

Maximum 5 files.
800 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.