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Gallantry Nomination Form

Thank you for your interest in nominating a member for Gallantry.

Please ensure you have answered all the questions below so that we have all the information we need to understand the act you are nominating the member for having done. Should we need more information you may be contacted by the nomination committee.

If you have any questions or would like to provide additional information beyond this form, please email

Description of Act

The description should include the date of the Act, a complete depiction of the actions of the individual involved and any factors identifying special circumstances assisting determination level of possible award, such as size of the individual involved related to the size of the person rescued/saved, weather conditions at the time of the incident if outdoors, currents or sea conditions if water involved, length of time/distance away from emergency resources such as police, fire, medical, and any other factors that would assist in adjudication. Did rescuer perform medical treatment, CPR?

Provide information about others involved and whether the rescuer’s life was in danger at any time.

The following information is also required based on the circumstances:

  • Fire – How close to flames did rescuer go? Did rescuer pass through or go near smoke or flames? Was there danger of explosion or falling debris?
  • Water – Name of body of water, depth of water, distance from shore and condition of shoreline, did rescuer use a boat, could rescuer swim, condition of water body (snags, branches, muddy or rocky bottom, etc.)?
  • Electrical – quantity of electrical current, danger from moving or dangling wires, presence of water or moisture, did rescuer climb on anything to effect rescue?

Please provide a complete narrative description on the following page and add any additional information that may assist – such as newspaper clippings, maps, police, fire or medical reports, etc.

Nominee's Information

Initiator's Information

You are strongly encouraged to record the narrative description in a saved document or email prior to copying the content onto this form in case the submission form fails to submit.

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