Request for approval of an award of a Commonwealth and/ or Foreign Order, Decoration or Medal to a Canadian Citizen

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Donor Country:

Proposed order, decoration or medal:

Name and address in Canada of proposed recipient:

Place of birth:

Date of Canadian citizenship (if born outside Canada):

Criterion under which it is proposed to make the award (indicate by placing an X in appropriate box):

(a) an extraordinary  service to mankind;

(b) conspicuous bravery in saving or attempting to save life;

(c) an exceptional service rendered to the country desiring to make the award;

(d) any substantial act or acts contributing to better relations between Canada and the country desiring to make the award.

Description of meritorious act(s) and/or achievement(s) for which the award will be made (use additional page(s) if necessary):


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