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(s) nominated:		Name: ........................................................................................................................................ Address: ..................................................................................................................................... Age: ............................... Occupation: ......................................
Person(s) rescued or attempted to be rescued:		Name: ........................................................................................................................................ Address: ..................................................................................................................................... Age: ............................... Occupation: ......................................
Time of Day, Date and place of incident:		Time: ......................................................................................................................................... Date:.......................................................................................................................................... Place: ........................................................................................................................................
Summary of rescue including risk incurred:
Result of rescue attempt:

Signature of 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.)

And 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.

(1) Name, address and occupation of declarant
(2) Here, set out the facts to be proved in the numbered paragraphs
(3) Signature of person before whom the declaration is made and their title