/ Application for Transfer of Membership / FBMH26.3.1
Queensland State Emergency Service
Surname / First Name
Membership No / Position/Rank

Current Details

Region / Area
SES Unit / SES Group

Transferring to

Region / Area
SES Unit / SES Group

New Contact Details(leave blank if not known & notifyArea Office as soon as confirmed)

Residential Address
Postal Address (Insert “AS ABOVE” if same as Residential Address)
Email
Home Ph / Work Ph / Mobile

New Emergency Contact Details (leave blank if not known & notify Area Office as soon as confirmed)

Name
Residential Address
Home Ph / Work Ph
Mobile / Relationship

I hereby certify that I have returned all equipment and property, including any keys/cards/codes,relevant tothe exiting SESUnit/Group, Area Office or local government.

I acknowledge that I will return all SES uniforms, personal protective equipmentand any other property of SES, QFES or local government if I do not complete the transfer.

SES Member Name / Date
Signature

FOR COMPLETION BY EXITING AREA

SES LOCAL CONTROLLER or delegate(Optional)

Name / Date
Signature
Comment on SES member’s operational and performance history:
Additional pages attached (if required): Yes No

AREA DIRECTOR

Name / Date
Signature / Member’s Position/Rank
Comment on SES member’s operational and performance history:
Additional pages attached (if required): Yes No

FOR COMPLETION BY RECEIVING AREA(Mandatory)

SES LOCAL CONTROLLER or delegate

Name / Date
Signature
Transfer accepted Yes No
Comment on SES member’s operational and performance history:
Additional pages attached (if required): Yes No

AREA DIRECTOR

Name / Date
Signature
Comment on SES member’s operational and performance history:
Additional pages attached (if required): Yes No

OFFICE USE ONLY

Membership classification on volunteer database / Active Reserve Other
SES Member’s file attached / Yes No
Form sent to receiving Area Office / Yes No / Completed by:
Copy of form sent toreceiving SES Local Controller / Yes No / Completed by:
Transfer accepted by receiving SES Local Controller / Area Director / Yes No / Completed by:
SES Member’s file transferred / Yes No / Completed by:
Volunteer database updated by receiving Area Office / Yes No / Completed by:
Updated ID card supplied by receiving Area Office / Yes No / Completed by:

Queensland Fire and Emergency Services is collecting the personal information on this form for the following purposes:

-to process and record a member’s transfer to another SES Group;

-to manage and provide training support; and

-for the Department to discharge its legislative, accountability, administrative, reporting, management, personnel and financial functions.

Collection of this information is authorised/required by the Disaster Management Act 2003.

For further information about privacy and other uses and disclosures of your personal information, refer to the Department’s Privacy Plan as amended from time to time, available on the Department’s website.

/ Page 1 of 2 / Date: 24/04/2014 / FBMH 26.3.1 v4 /