Long service award request form

1. Which award are you eligible for? *

   • 25 years
   • 40 years
   • 50 years
   • 60 years
   • 70 years
2. What is your registration number?
3. What date were you appointed? * If you don't know the exact date, please provide as much information as possible (e.g. month / year).
4. Which state electorate do you live in? * If you are unsure, you can check on this interactive map. Please enter your full address to ensure the result is accurate. —please select—AlgesterAspleyBancroftBarron RiverBonneyBroadwaterBuderimBulimbaBundabergBundambaBurdekinBurleighBurnettCairnsCallideCaloundraCapalabaChatsworthClayfieldCondamineCookCoomeraCooperCurrumbinEvertonFerny GroveGavenGladstoneGlass HouseGreenslopesGregoryGympieHervey BayHillHinchinbrookInalaIpswichIpswich WestJordanKawanaKeppelKurwongbahLockyerLoganLyttonMacalisterMackayMaiwarMansfieldMaroochydoreMaryboroughMcConnelMermaid BeachMillerMiraniMoggillMorayfieldMount OmmaneyMudgeerabaMulgraveMundingburraMurrumbaNanangoNicklinNinderryNoosaNudgeeOodgerooPine RiversPumicestoneRedcliffeRedlandsRockhamptonSandgateScenic RimSouth BrisbaneSouthern DownsSouthportSpringwoodStaffordStrettonSurfers ParadiseTheodoreThuringowaTooheyToowoomba NorthToowoomba SouthTownsvilleTraegerWarregoWaterfordWhitsundayWoodridge

1. Name

   1. Given name *
   2. Family name *
2. Were you originally appointed under a different name? *

   • Yes
   • No
3. What name/s were you originally appointed under? *
4. Date of birth * Example: 12/07/1989
5. Address

   1. Address line 1 *
   2. Address line 2
   3. 1. Town, city or suburb *
      2. State *
      3. Postcode *
6. Email * Example: jane.smart@example.com
7. Phone * Home, mobile or work number

Please confirm that you:

1. Acknowledgement

   * agree to your application being sent to your local Member of Parliament for nomination
2. Acknowledgement

   * acknowledge you are the person listed above
3. Acknowledgement

   * have read and agree to the privacy statement. View the privacy statement.