First Name:

Last Name:

Date of Birth:

Address:

Telephone Number:

E-Mail Address:

Vicpol Registered Number:

Rank at Retirement:

Date of Retirement:

Military Number:

Military Unit Served:

Any Police or Military Awards? Any Police or Military Awards? Yes No

Please state your Police or Military Awards Here

Any Overseas Deployments? Any Overseas Deployments? Yes No

Please state your overseas deployment/s here

Permission for your name on the Honour Board? Permission for your name on the Honour Board? Yes No

Willingness to be interviewed for oral history? Willingness to be interviewed for oral history? Yes No

Interest in attending a Dedication Service (including families)? Interest in attending a Dedication Service (including families)? Yes No

Any Comments?