Fillable Printable National Service Medal Application Sample Form
Fillable Printable National Service Medal Application Sample Form
National Service Medal Application Sample Form
AD 180 - Page 1 of 2
AD 180
Revised Nov 2005
Application for the
Anniversary of National Service 1951 - 1972 Medal (ANSM)
Department of Defence
The ANSM has been established by a grateful nation to commemorate an important element of Australia's military and
cultural heritage. You are encouraged to send this form through your local Federal Member of Parliament or Senator,
who will then arrange a formal presentation of the medal.
If you do not choose the above option, please post the completed form to:
Directorate of Honours and Awards
T-1-49
Department of Defence
CANBERRA ACT 2600
Telephone: 1800 111 321
Applications will be processed in order of receipt and are
subject to verification by the Department of Defence.
As approximately 300,000 National Servicemen will be entitled
to this new medal, your continued patience will be appreciated.
Notes:
1. Use BLOCK letters only.
2. Please complete the entire form and provide details of ALL Australian Defence Force service.
3. You should attach Certified True Copies of any relevant documentation that may support and expedite your application.
4. If claiming for a deceased person, the Statutory Declaration on page 2 must be completed instead.
5. Copies of this form may be downloaded from the Honours and Awards section at www.defence.gov.au/dpe
AUSTRALIA
STATUTORY DECLARATION
To be completed only by the FORMER National Serviceman. All deletions or corrections are to be initialled.
I
(full name)
of
(full address)
Postcode
Here insert title and full name of the person making the declaration.
Phone number
do solemnly and sincerely declare:
That I served in the Australian Defence Forces and that my details were as follows:
Rank Family name Given name(s) Date of birth
Service number(s) Branch of service
Navy Army Air Force
Date(s) of enlistment Date(s) of discharge
Service number(s)
Navy Army Air Force
Date(s) of enlistment Date(s) of discharge
Unit(s) Any additional information
I declare that the information provided above is true and correct regarding my service, that I had an obligation to
serve under the National Service Act 1951-1971, and that I fulfilled that obligation.
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 in
this declaration to be true in every particular.
Signature of person making declaration
Declared at , on the , 20
before, me
Signature of person before whom the declaration is made
Title of person before whom the declaration is made
DHA contracts out to third party entities the assessment and despatch functions of certain Defence medals. Accordingly,
DHA may disclose some of your personal information such as name, postal address and service number to these contracted
third parties. However, it is only for the purposes of assessment, engraving, despatch and correspondence in regards to
medals entitlements. By signing this application form you acknowledge this disclosure.
Use and disclosure of personal information
AD 180 - Page 2 of 2
Application concerning the Posthumous Issue of the
Anniversary of National Service 1951 - 1972 Medal (ANSM)
Department of Defence
AUSTRALIA
STATUTORY DECLARATION
This Statutory Declaration may only be completed by the person who believes that they have the
highest legal claim in accordance with the order of entitlement shown in the note above.
I
(full name)
of
(full address)
Postcode
Here insert title and full name of the person making the declaration.
Phone number
do solemnly and sincerely declare:
That I wish to apply for the unclaimed Anniversary of National Service 1951-1972 Medal in respect of the following deceased
ex-member:
Rank Family name Given name(s) Date of birth of veteran
Service number Branch of service
Navy Army Air Force
Date of enlistment Date of discharge
and believe I am the person entitled to receive the Anniversary of National Service 1951-1972 Medal.
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 in
this declaration to be true in every particular.
(b) Public Trustee Administrator in cases of intestacy
Notes:
1. Posthumous and unclaimed Medals or Awards for a deceased veteran may only be issued to persons in accordance
with the order of entitlement below:
(a) Executor of the will
2. Applications will be processed in order of receipt and are subject to verification by the Department of Defence.
3. Copies of this form may be downloaded from the Honours and Awards section at www.defence.gov.au/dpe
(c) A person who can provide legal proof to their status as the sole beneficiary to the claim being made for posthumous
issue of the Service award(s) (if such proof cannot be tendered, the entitlement remains unclaimed and may lapse)
All deletions or corrections are to be initialled.
Date veteran deceased
I declare that I am
Insert title of relationship from note 1 above
to the above deceased ex-member,
Signature of person making declaration
Declared at , on the , 20
before, me
Signature of person before whom the declaration is made
Title of person before whom the declaration is made
DHA contracts out to third party entities the assessment and despatch functions of certain Defence medals. Accordingly,
DHA may disclose some of your personal information such as name, postal address and service number to these contracted
third parties. However, it is only for the purposes of assessment, engraving, despatch and correspondence in regards to
medals entitlements. By signing this application form you acknowledge this disclosure.
Use and disclosure of personal information
