Memorial Memento Application · Memorial Memento Application. The RCMP Memorial Memento is...
1
Protected B once completed Memorial Memento Application The RCMP Memorial Memento is presented in respect of a fallen member whose name appears on the official RCMP Cenotaph, Memorial Wall Plaque and Honour Roll Book. This Memento is presented to living next-of-kin to a maximum of three Mementos per fallen member. Complete a separate application for each memento. Fallen Member Surname Given Names Rank Regimental Number Applicant Information The Memento is issued in respect of a fallen member to only the following persons (total of three (3) per family), described as next-of-kin, namely: 1. to the mother, if alive; 2. to the father, if alive; 3. to the spouse or common-law partner, if alive; 4. where there is no person referred to in 1), 2) or 3), to the eldest living child; 5. where there is no person referred to in 1), 2), 3) or 4), to the brother or sister, if alive, whichever is eldest. Relationship to the fallen member Mother Father Spouse or Common-law Partner Eldest Child Eldest Sibling Surname Given Name Email Daytime Telephone Number Evening Telephone Number Address To be signed by the Applicant receiving the Memento or by Parent / Guardian if the Applicant is under 16 years of age. I declare that the information provided is true and correct. I agree that the information provided may be used to process this application for the RCMP Memorial Memento. Signature of Applicant or Parent / Guardian Date (yyyy-mm-dd) Send completed form by mail to: Royal Canadian Mounted Police Honours and Recognition 73 Leikin Drive, Mail Stop 48, Ottawa, ON K1A 0R2 Or by fax to: 613-825-4689 RCMP GRC 5186e (2016-06) Page 1 of 1 Personal information is collected for the purpose of determining eligibility for the issuance of the RCMP Memorial Memento. All personal information collected, used, disclosed, retained and disposed are governed by the provisions of the Privacy Act. A request to access personal information shall be made in writing to: RCMP, Access to Information and Privacy Coordinator, 73 Leikin Drive, M3-2-202, Mail Stop 61, Ottawa, ON K1A 0R2 For more information, visit our website or contact us by email at [email protected] Submission Instructions
Transcript of Memorial Memento Application · Memorial Memento Application. The RCMP Memorial Memento is...
Protected B once completed
Memorial Memento ApplicationThe RCMP Memorial Memento is presented in respect of a fallen member whose name appears on the official RCMP Cenotaph, Memorial Wall Plaque and Honour Roll Book. This Memento is presented to living next-of-kin to a maximum of three Mementos per fallen member. Complete a separate application for each memento.
Fallen MemberSurname Given Names
Rank Regimental Number
Applicant InformationThe Memento is issued in respect of a fallen member to only the following persons (total of three (3) per family), described as next-of-kin, namely:
1. to the mother, if alive;2. to the father, if alive;3. to the spouse or common-law partner, if alive;4. where there is no person referred to in 1), 2) or 3), to the eldest living child;5. where there is no person referred to in 1), 2), 3) or 4), to the brother or sister, if alive, whichever is eldest.
Relationship to the fallen member
Mother Father Spouse or Common-law Partner Eldest Child Eldest Sibling
Surname Given Name
Email Daytime Telephone Number Evening Telephone Number
Address
To be signed by the Applicant receiving the Memento or by Parent / Guardian if the Applicant is under 16 years of age.
I declare that the information provided is true and correct. I agree that the information provided may be used to process this application for the RCMP Memorial Memento.
Signature of Applicant or Parent / Guardian Date (yyyy-mm-dd)
Send completed form by mail to: Royal Canadian Mounted Police Honours and Recognition 73 Leikin Drive, Mail Stop 48, Ottawa, ON K1A 0R2 Or by fax to: 613-825-4689
RCMP GRC 5186e (2016-06) Page 1 of 1
Personal information is collected for the purpose of determining eligibility for the issuance of the RCMP Memorial Memento. All personal information collected, used, disclosed, retained and disposed are governed by the provisions of the Privacy Act. A request to access personal information shall be made in writing to: RCMP, Access to Information and Privacy Coordinator, 73 Leikin Drive, M3-2-202, Mail Stop 61, Ottawa, ON K1A 0R2 For more information, visit our website or contact us by email at [email protected]
Submission Instructions
