NOMINATION FOR AWARD FORM

Please use the form below and if possible send by email, preferably in Word, to RoyalHumaneSociety@fire.nsw.gov.au

Alternatively, the form can be completed and forwarded to:

Royal Humane Society of New South Wales Inc,
PO Box A830
Sydney South NSW 1235

The Statutory Declaration available on our website must be completed and forwarded by the person making the nomination(s) to the PO Box above.

Only one form is to be provided for all nominees involved in an incident.

Please note that nomination(s) must be made within 5 years of the incident.

The nominee(s)
With regard to each person nominated please provide:

Full name and address.

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Age and occupation (if known).

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Telephone numbers (if known).

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Whether the person has been nominated for any other awards of which you are aware.

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Any other relevant information about the nominee.

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Person(s) rescued or attempted to be rescued
With regard to each person rescued or attempted to be rescued please provide:

Full name and address.

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Age (if known).

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Telephone numbers (if known).

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Any other relevant information about the person.

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Incident giving rise to nomination

Date, time and place of incident.

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If relevant, weather and other prevailing conditions.

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Were you present when the incident occurred? If not please indicate the source of your knowledge about it.

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Describe the facts of the rescue in chronological order and what action each nominee(s) took including the degree of risk involved.

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Details of any emergency services in attendance (e.g. police, ambulance, fire).

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If you are aware of any court proceedings arising out of the incident e.g. inquest, criminal charge please provide details.

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Result of rescue attempt.

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Supporting documents

Please furnish an itemised list of all documents provided in support of the nomination(s).

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Particulars of person nominating

Full name and address.

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Occupation.

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Daytime telephone number and mobile number

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Email address.

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Relationship to any persons nominated.

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Date of completion of nomination form. Click or tap to enter a date.

Signature of person nominating

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