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MODMO Reference Number:Ministry of Defence Medal Office (MODMO) - Medal Application Form

(Please complete in BLOCK CAPITAL)

Please note! Medals a"arded prior to t#e econd $orld $ar can no lon%er &e iss'ed

I "is# to apply for a

Part ! eteran*s+ er,ice Person*s Details!

Title

Surname

Other names

Surname (if different in Service to above)

Date of Birth / /

Service Number

Service RN/RM Arm RA! Reservists

Service/ Re"iment/ #or$s on enlistment

Service/ Re"iment/ #or$s on dischar"e

Details of an other Militar or #ivil Defenceservice

Ran% (on dischar"e)

Dates of Service /

/ to / /

Details of overseas service

If yo' are t#e ser,ice person detailed a&o,e please %o to part .&'/' T#e Medal Form

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Part /! Applyin% on &e#alf of a li,in% eteran+ er,iceperson

0o' m'st #old Po"er of Attorney if yo' are applyin% for t#e person detailed in part 1

*

#onfirm that hold +o,er of Attorne for

and enclose a co$* not an ori"inal* ,ith this a$$lication-

2o" please %o to part .

Part /a! Applyin% on &e#alf of a Deceased eteran+ er,iceperson

0o' m'st &e t#e official 2e3t of Kin (2oK) in order to apply

The Official No. is the first $erson from the follo,in" list ,ho is still alive- +lease tic% the relevantbo (This order is based on ntestac 0a,)

Survivin"

S$ouse

1ldest

child

+arent 1ldest

"randchild

2rand$arents

Brotherof the,holeBlood

Sisterof the,holeBlood

Brotherof thehalfBlood

Sisterof the halfBlood

Ne$he,of the,holeBlood

Niece ofthe,holeBlood

Ne$he,of the halfBlood

Niece ofthe halfBlood

Other

The Service$erson/ 3eteran4s date of death ,as

/

/

+lease enclose a co$ of the $erson4s death certificate or their notification of death(this is not re5uired if the died in service)

*

confirm that am the official No. for

2o" please %o to part .

Part .! Consent for email correspondence

I 'nderstandthat corres$ondence transmitted b email ma be o$en to abuse because it istransmitted over an unsecured net,or%- acce$t that the Ministr of Defence (MoD) ,ill not be liablefor an loss* interce$tion or unauthorised use of information transmitted this ,a- "ive authorit forthe MoD to corres$ond ,ith me via the email address have $rovided on this form-

I a't#orisethe MoD Medal Office to use email ,henever $ossible in its corres$ondence ,ith me viam nominated email address sho,n on the front of this claim form- acce$t that the information mainclude m $ersonal details and an other information that could com$romise m identit-

Are yo' #appy for 's to correspond ,ia email "it# yo'4(+leasetic% bo and remember to detail our address in +art )

6es No

Data Protection

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The MoD is a Data #ontroller for the Data +rotection Act '778- 9nder the act ou have a ri"ht ofaccess to our $ersonal information held b the 3eterans 9.- f ou ,ant to as% for a co$ of thatinformation* $lease ,rite to us 5uotin" our National nsurance number-

The MoD is committed to ensurin" that all our $ersonal data is $rocessed in accordance ,ith theData +rotection Act '778-

The $ersonal data (includin" sensitive $ersonal data* for eam$le information about our $hsical ormental health or condition) collected and contained ,ithin this form ,ill be retained on our $hsicalfile and ma be used for all la,ful $ur$oses includin":

b the MoD and its a"ents in connection ,ith all matters relatin" to the A!#S claim or a

ar +ension claim and an other claims a"ainst the MoD

b other 2overnment De$artments ,hich have a le"itimate interest in this information for

eam$le for the $ur$oses of research or for the $revention and detection of crime-

Part 5! Declaration

2o" complete yo'r f'll details si%n t#en print off t#is form and finally post it to t#e address

s#o"n &elo"

I confirm t#at t#e information I #a,e %i,en is acc'rate and complete to t#e &est of my6no"led%e and &elief1

Si"nature +rint name

Date

/ /

Address Tele$hone number

1mail address

+ostcode

T#e Ministry Of Defence Medal Office (MODMO)Inns"ort# 7o'se Im8in Barrac6s Inns"ort#9lo'cester 9lo'cesters#ire 9L. 7$

7a,e yo' remem&ered to attac# copies not ori%inals of t#e Deat# Certificate t#e Po"er ofAttorney or any ot#er rele,ant information "#ic# co'ld &e 'sed to process yo'r application