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The Royal Humane Society of Australasia Inc
Level 9, Casselden Place, 2 Lonsdale Street, Melbourne 3000
 
 
  Telephone:
(03) 9650 3233
  
PO Box 18192
  Fax:
(03) 9650 5488
  
Collins Street East
  E-Mail:
bravery@rhsa.org.au
  
Melbourne 8003
  Web site:

www.rhsa.org.au

 

 
giving public recognition since 1874 to acts of bravery by making awards to those who risk their lives to save or attempt to save the lives of others
 

APPLICATION FOR AN AWARD

Person
Nominated:
 Name:
Address:
Age:
Occupation:
Person
rescued or
attempted to
be rescued:
 Name:
Address:
Age:
Occupation:
Time of Day,
Date and place
of incident:
 Time:
Date:
Place:
Summary of
rescue
include risk incurred:
Result of
rescue
attempt:
Applicant:
 Name:
Address:
Telephone: (H) (W)

Please complete the Statutory Declaration below to describe the rescue. This form should then be accompanied by eye-witness statements and other relevant documents giving as complete details as possible. The degree of risk should be described as the class of award which may be decided depends on the degree of risk by the rescuer.

 

Note: Applications should be made within TWELVE MONTHS of the date of the rescue.

 

Declaration under the Statutory Declarations Act 1959 - Commonwealth

 

Statutory Declaration

This Declaration must be made before a Justice of the Peace, a Commissioner for Affidavits or Declarations, a Magistrate or other person referred to in Section 8 of the Statutory Declarations Act 1959, and should contain the name in full, the occupation, and the place of abode of the person making it; together with a full and precise Statement of the Claimant's exertions, and of THE ACTUAL RISK thereby incurred.)

I (1),
do solemnly and sincerely declare as follows (2)

 

By ticking this box I acknowledge that I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in this declaration to be true in every particular.

DECLARED on

 

the day of 20


(1) Name, address and occupation of declarant
(2) Here, set out the facts to be proved in the numbered paragraphs