A PERSONAL PARTICULARS
(TO BE COMPLETED IN BLOCK LETTERS)
Surname (in which service was rendered)
National Registration No.
Christian or First names in full
Nationality if not British
STATE WHETHER MR., MRS. OR MISS OR ADD ANY OTHER PREFIX
Aliens Registration No.
Full Postal address to which Medal Ribbon should be sent (add surname if it is now different from that above)
B PARTICULARS OF QUALIFYING SERVICE.
NOTE : Space is provided for entering three separate periods served in succession. Entries for separate periods should be made in sequence, starting with the earliest period. These particulars must be given whether or not a qualifying Award or King's Commendation or Wound Stripe have been earned.
PERIOD(S) OF SERVICE
Rank at end of period of service.
NAME and ADDRESS of AUTHORITY or EMPLOYER. N.B.- If service was in Category 16 state where the duties were performed. If in Category 17 add address of premises where duties performed and name of department in the premises where you worked. Full time Fire Guards should state “Full Time”
Category No. of service. (see para.15 of instructions.)
From
To
Total of each period
Month
Year
Month
Year
Year
Month
TOTAL PERIOD
State qualifying Award or King's Commendation (if any) and date of
If awarded a Wound Stripe give particulars and date(a copy of the official notification of the award must be attached to this form).
C CERTIFICATE BY CLAIMANT.
I certify that to the best of my knowledge the information given above is correct. I claim that I am entitled to the award of the Defence Medal by virtue of the above service (
*
and of the service claimed on forms D.M.3 and/or 4 attached) and I certify that I have not made any other claim for the Defence Medal.
