Protected B
(When Completed)

Honours and Awards Medals Application for Civilians and Retirees
Application Procedure

Please submit a copy to the Directorate of History and Heritage BY MAIL ONLY. We can not complete your application without a signed copy of the application.

You are also requested to attach documentary proof of service (BY MAIL ONLY) along with this request. This will speed the approval of your request.
For Service Number, Please do not enter in your SIN number.

Member Information:
Service No.: Last Name: Rank:
SIN:                                   Initials: Enviro. Code:
Regimental No.:                                   First Name: Member Type:
Release Date:    Deceased Date:    Eligibility Unit:
MM     DD     YY MM     DD     YY Eligibility Rank:
Medal Selection

Please select the medal for which you are applying. If this is a request for a replacement medal please select the replacement check box.
 
Medal Type:


Replacement: 		Qualifying Service Period:

Notes:

Use this Field to Supply Dates and Places of Duty
and Previous Medal Awards. 

Please do not provide any Classified information.

Check box if you have Classified information and DHH will contact you for procedures on how to send this information:

Next of Kin Information:

Are you submitting this application on behalf of someone else?
If you are submitting this request on behalf of someone else complete this section. Otherwise you may proceed to the next section.
Last Name: Initials: First Name:
Relationship:

Mailing Address:

Please indicate whether the mailing address is for someone other than the person entitled to receive this award. The mailing address is where the medal will be delivered.
 Next of Kin
Individual to receive award
Email:
Address 1:
Address 2:
City:               Postal Code: Home Phone:
Province: Country: Work Phone:
Fax Number:
Presenter's Information

In the case of the Canadian Peacekeeping Service Medal use this section to identify the organisation (sponsor) or person (contact) that will present the medal to you.
Sponsor:   Contact Last Name:    Contact
First Name:
Email:
Address 1:
Address 2:
Address 3:
Address 4:
City:              Postal Code: Home Phone:
Province: Country: Work Phone:
Fax Number:
Signature and Submission

Please print, sign and MAIL the form (along with supporting documents).

PRIVACY/SECURITY NOTICE

DO NOT FAX OR E-MAIL any application forms nor substantiating documentation.
SUBMIT BY MAIL ONLY to:


Directorate of History and Heritage (DHH) 4-3

Bldg 347 Uplands Site
MGen George R. Pearkes Bldg
101 Colonel By Drive
Ottawa ON
Canada K1A 0K2

_____________________________________________
Signature
___________________________
Date
Protected B
(When Completed)