Honour Roll application

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Required fields are marked with an asterisk (*).

Details of person to be included on the Honour Roll

First name(s) *

Last name *

Date of birth *

Date of death *

Age at death *

Occupation *

Photo uploads (optional)

You can upload up to 3 photographs, with no larger than 5 MB file size each and match one of the following extensions: .gif, .jpeg, .jpg, .png, .tiff

Photo 1

Photo 2

Photo 3

Written tribute (optional)

Your tribute can be any length. We recommend between 200 and 1000 words. If your tribute is greater than 1000 words, please upload on a Word document (doc or docx). For help writing your tribute please read the guide or call 1300 362 128.

Written tribute

Upload written tribute Uploaded file can be no larger than 5 MB and match one of the following extensions: .doc, .docx, .pdf

Details of the person submitting this application

First name *

Last name *

Phone number *

Email address *

Relationship to the deceased *

Declarations

Are you aware of any current legal action regarding the death of the individual I wish to register for inclusion on the Honour Roll? *

If Yes, please provide details What type of legal action? Which court the proceedings are in? When the action is expected to be resolved?

Next of kin * Are you authorised as next of kin and have the support of the individual’s family and individuals identified in the tribute to submit this information.

True and accurate * The information I have provided is true and accurate and that I am aware that providing misleading, deceptive, or false representations can amount to a criminal offence and give rise to civil liability. I acknowledge that my personal information will only be used for the purposes of administering the Honour Roll and related purposes, and will not be used for other purposes or disclosed to third parties without my consent.

Criteria for inclusion on the Honour Roll * I have read and understood the criteria for inclusion on the Honour Roll and consider that this individual meets the criteria. The criteria can be found on the Queensland Workers Memorial website.

Privacy statement

The Office of Industrial Relations is collecting your personal information for the purposes of responding to your registration request. Your personal information may also be used for the purpose of reviewing our client service performance and standards.

Honour Roll application

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