CPOMA Application for Induction

1.    (a) Full Name of Fallen Officer:

        (b) Name to be recorded on Memorial:

2.    Date of Birth: (day-month-year):

3.    Date of Death: (day-month-year):

4.    Rank/Title:

5.    Name of Department/Agency (on date of death):

        (a)  Address:

        (b)  Contact Person:

6.    Date of Appointment (day-month-year):

7.    (a)    Submitting Department/Agency:

        (b)    Address:

        (c)    Contact Person:
        (include telephone #, email, etc.)

8.    Next-of-Kin:
        (include names, relationship, addresses, telephone #s, email, etc.)


9.    Full details of incident causing death:

10.  Photograph:  Attached _______

_______________________________________
Signature of Representative of Submitting Party
_____________________________________________________________
For CPOMA Use Only:      Approved   ___        Denied ___

_______________________________________
Signature of Awards Committee Member