Distinguished Service Medal Nomination

Distinguished Service Medal Nomination

Surf Life Saving Queensland
SLSQ and its members are committed to saving lives and continually working towards its vision of ‘zero preventable deaths in Queensland public waters’. Surf Life Saving Queensland (SLSQ) is the State’s peak beach safety and rescue authority comprising of 58 surf lifesaving clubs, 80 lifeguard services and close to 35,000 dedicated individuals (volunteers and staff).

The Surf Life Saving Queensland Distinguished Service Medal has been introduced and is awarded to members both present and past who have provided distinguished, extraordinary and outstanding service to the association for a minimum for 15 years.

Surf Life Saving Queensland recognises the sustained and significant commitment to those persons who have provided distinguished service in response to SLSQ’s volunteer organisation and vision.

In preparing the nomination the Panel requires a detailed account of the nominee’s service and referee statements, particularly addressing how the nominee’s service could be considered extraordinary.

Application by former volunteer and staff members
- Living former members who meet the eligibility criteria as outlined in this document may apply in writing to the Life Members & Civil Honours Panel, to the effect that their exceptional meritorious service was of sufficient duration to meet the eligibility criteria.
- Applications for the SLSQDSM can also be made on behalf of the former member by a current SLSQ member or a family member.
- Where an application is made on behalf of a former member, a covering letter with the application form outlining how the (the nominees) exceptional meritorious service is sufficient to meet the eligibility criteria must be attached. The nomination shall be void this is not attached.
What is Distinguished Service?

A person who has rendered extraordinary, outstanding and conspicuous service to the Association, personal sacrifice above and beyond normal duties.

Who may make a nomination?

Anyone may make a nomination by completing the nomination form.

Who can be nominated?

Anyone may be nominated by completing the nomination form.

Confidentiality

All nominations are strictly confidential and the information provided will be used to assist the Panel in considering the merits of the nomination.

Please note

A seperate nomination form must be submitted for each individual.

All nominations are submitted to the Branch for endorsement prior to being submitted to the State for review.

SECTION 1 - NOMINATORS INFORMATION
Please provide your contact details to enable officers of the SLSQ Life Members & Civil Honours Panel and/or Panel Secretary to seek further details if required.
Title
Name*

SurnameGiven Names
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position/Title
SLSQ Club Name
SLSQ Branch Name
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

SECTION 2 - NOMIEE INFORMATION
Tell us about the person you are nominating for the Distinguished Services Award.
Title
Name*

SurnameGiven Names
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position/Title
SLSQ Club Name
SLSQ Branch Name*
SLSQ Branch Email*
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date

SECTION 3 - NOMINEES ACTIVITIES
In this section, space has been provided for you to set out details of how the nominee has made a significant contribution to the community, including any position held/activities undertaken, together with relevant dates of service.

Please include a statement in your words about why you think the person should be singled out and recognised by SLSQ Distinguished Service Award.
In what role(s) or area(s) has the nominee excelled?*
How has the nominee demonstrated serviceworthy of recognition?*
How has the nominee’s contribution impacted on its club/branch/state?*
Over what period of time has the nomineemade major commitment?*
What makes the nominee stand out from others?*
Please provide your statement information to support this application*
Please update any supporting documentation for the application*

Cancelof
Nominations declaration - signing this box confirms that all information provided on this form is accurate and true to the best of your knowledge

Clear
If required, we might need to contact your for further information. Please indicate below*
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Distinguished Service Medal Nomination

SECTION 1 - NOMINATORS INFORMATION

SECTION 2 - NOMIEE INFORMATION

SECTION 3 - NOMINEES ACTIVITIES