Remote Service Ribbon for Retired or Resigned Members Application Form

The Northern Territory Police Force (NTPF) Remote Service Ribbon may be awarded to recognise members who have completed two (2) years cumulative service in areas that have been specifically gazetted as remote or track stations listed in the Police Consent Agreement in force at the time of application. Subject to the following inclusion: Cumulative service excludes gazetted remote service where a member received a travel allowance or similar. For example, members who undertook short-term gazetted tenures and received a financial allowance, such as Operation Themis and Operation Pleach. Do not include this service period in your calculations for eligibility on this form.

Members gazetted to an eligible remote station who, during their tenure, are required to perform duties at a non-remote station for higher duties or to assist in the effective management of the NTPF will remain eligible for the RSR, provided they complete a total of 2 years of cumulative service at an eligible station.

Please complete section 1 of the application form. Gazetted documentation verifying eligible service dates (start and end dates) is required to be attached to the application when emailed to HonoursandAwards.PFES@pfes.nt.gov.au

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

Unlimited number of files can be uploaded to this field.
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.