Refer to the Gurney Fund This form is for the sole use of an authorised representative to notify the fund of an applicant’s details. Refer Form The form to be used by forces contacts to refer somebody Force(Required) Fund Reference for fund use onlyOfficer's DetailsName First Last Address Street Address Address Line 2 City ZIP / Postal Code Date of Death DD slash MM slash YYYY ORDate of Medical Retirement DD slash MM slash YYYY Cause of Death or Medical RetirementMarital Status(Required) Married or Domestic Partnership Separated Divorced Duty Status(Required) On Duty Off Duty Retired Spouse / Partner / Guardian’s DetailsName First Last Different address from officer's address? Yes Address Street Address Address Line 2 City Post Code PhoneEmail Child's DetailsChild's Details Name Date of Birth Please upload a copy of child's birth certificate Actions Edit Delete There are no Child Details. Add Child Details Maximum number of child details reached. Referred ByName First Last Email PhoneReferral capacity Local Representative Federation Representative Other Notes: Background information which may be of relevance to the applicationConsent I agree to the privacy policy. Δ
