Long Service Medal (LSM) Nomination Form

Page 1

The Duke of Edinburgh's International Award - Australia

Recipient Details

First Name

Last Name

Address

Postcode

Mobile

Application Details

Long Service MedalAdditional 10 Year Medal Service Clasp

Proposed Medal Presentation Date

Recipient Award Service History

Upon completion of this form, you must upload supporting documentation to verify service for each new role, and/or Award Centre.

Award Centre/Organisation/Award Level

Role

Date From

Date To

Brief description of service

List supporting documentation to be uploaded

Additional Notes

Nominator Details

Nominations can be made by the recipient or a nominator. Leave blank if applicant is recipient.

Note: The nomination is being made to the National Medals & Awards Committee, who engages the Award Operating Authority to review and approve Long Service Medals on behalf of the National Board

First Name

Last Name

Address

Postcode

Award Unit/Organisation

Role

Relationship to Recipient

Mobile

Referee Details

A Referee is not required if the nominator is the Division Office

First Name

Last Name

Award Centre/Organisation

Role

Relationship to Recipient

Mobile

Supporting Documentation

List then upload at the end of the form

State/Territory Award Office Recommendation

First Name

Last Name

Relationship to Recipient

Mobile

Supporting Documentation

List and upload at the end of the form

Supporting Documentation

Award Centre Supporting Documentation

Referee Supporting Documentation

State/Territory Award Office Supporting Documentation

Contact Information