AUSTRALIAN INDUSTRIAL RELATIONS COMMISSIAUSTRALIAN INDUSTRIAL RELATIONS COMMISSION

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Form R19 Application for relief in respect of termination of employment (rule 37) ```html <table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td style="width:234.6pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Australian Industrial Relations CommissionApplication for relief in respect of termination of employment</td><td style="width:103.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Commission use onlyfile number</td></tr><tr><td style="width:234.6pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Workplace Relations Act 1996 (Cth)Subsection 170CE (2) or (4)</td><td style="width:103.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">date received</td></tr><tr><td colspan="2" style="width:348.6pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">This Form is to be completed in respect of an application to the Commission for relief in respect of termination of employment solely on the ground of an alleged contravention of section 170CL of the Workplace Relations Act 1996.Section 170CL states:“(1) This section applies if an employer decides to terminate the employment of 15 or more employees for reasons of an economic, technological, structural or similar nature, or for reasons including such reasons.(2) As soon as practicable after so deciding and before terminating an employee’s employment because of the decision, the employer must give to the body (if any) prescribed by regulations made for this subsection or, failing the prescription of such a body, to the Secretary of the Department, a written notice of the intended terminations, in a form prescribed by the regulations, that sets out:(a) the reasons for the terminations; and(b) the number and categories of employees likely to be affected; and(c) the time when, or the period over which, the employer intends to carry out the terminations.(3) The employer must not terminate an employee’s employment pursuant to the decision unless the employer has complied with subsection (2).”.</td></tr></tbody></table> ``` In making this claim you (the applicant) should be aware that: - specified categories of employees are excluded from making a claim under the Termination of Employment provisions of the Workplace Relations Act 1996. - an application lodged more than 21 days after the day on which the employee is given notice of the decision to terminate the employee’s employment can only be accepted if the Commission decides it would be unfair not to do so. - section 170CJ of the Workplace Relations Act 1996 allows, in certain circumstances, the Commission to make an order for costs - Section 170CEAA of the Workplace Relations Act 1996 requires a fee of $52.40 to be paid on lodgment of this application in the Commission unless a Registrar has approved the waiving of the fee. The $52.40 lodgment fee is refundable under certain circumstances Details in relation to these matters are available from the Industrial Registry. ```html <table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Details of employer alleged to have contravened section 170CL</td></tr><tr><td colspan="2" style="width:129.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">1 employer’s namecontact person</td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">…………………………………………………………………………………………………………</td></tr><tr><td colspan="2" style="width:129.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">2 employer’s trading address or registered office</td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">………………………………………………………………………………………………… ……..…………………………… Postcode …………phone (….) ………………… Fax (….) ………</td></tr><tr><td colspan="2" style="width:129.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">3 date notice of decision to terminate employee’s employment was given.</td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">/ /</td></tr><tr><td colspan="2" style="width:129.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">4 other employment details</td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">State the name of the award or agreement (including Australian Workplace Agreement) under which the employees are*/ were employed……………………………………………………</td></tr><tr><td colspan="2" style="width:129.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">State whether the award or agreement is State or Federal Federal State If State, name of State: …………</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#d8d8d8">5 About the employees</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Here insert name and address of employee/s whose employment has been* / is proposed to be* terminated by the employer………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">6 Brief summary of reasons given for termination or threatened termination (or attached)…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Extension of Time</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">7 This section to be completed if the application is lodged more than 21 days after the day on which the employee is given notice of the decision to terminate the employee’s employment (see Item 3 above). In such cases, the Commission must decide whether to accept the application. My reason/s for seeking an extension of time to lodge this application is/are:(or attached)</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5"><a id="_Toc108855926">Details of Union</a></td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">8 Is your union acting on your behalf</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">No  go to 11Yes  go to 9</td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">9 name and address of union</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">………………………………………………………………………………………………………………………………….. Postcode</td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">10 union contact person</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">……………………………………………………phone (…..) …………… Fax (…..) …………</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Details of representative</td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">11 Is anyone representing you?</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">No  go to 15Yes  go to 12</td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">12 name of solicitor or representative’s firm</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">13 name of contact person</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td colspan="3" style="width:135.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">14 address</td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">……………………………………………………………………………………………… ……..………………………… Postcode …………phone (….) ………………… Fax (….) ………</td></tr><tr><td colspan="7" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Notices from the Commission</td></tr><tr><td style="width:115.1pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">15 Where do you want notices from the Commission sent?(choose one only)</td><td colspan="4" style="width:74.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">address in 5 </td><td style="width:67.15pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">union in 9 </td><td style="width:59.7pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">other in 12  give details</td></tr><tr><td colspan="7" style="width:348.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Declaration</td></tr><tr><td colspan="7" style="width:348.6pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><img src="image.003.png" width="2" height="2" alt="" style="margin-top:-40.3pt; margin-left:122.6pt; position:absolute">I declare that no proceedings in respect of the termination that is the subject of this claim have been commenced (other than proceedings that have since been discontinued or failed for want of jurisdiction) in respect of or on behalf of the employee under any other provision of the Workplace Relations Act 1996 or under any other law of the Commonwealth or of a State or Territory.I further declare that all the facts in this application are correct and complete to the best of my knowledge and belief.</td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">The employee must sign this declaration*</td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Signature of employee………………………………………date / /</td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">If a solicitor or authorised representative has prepared the application, that person must sign here</td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Signature of solicitor or representative………………………………………date / /</td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">If a union or an inspector is applying on behalf of the employee, a union representative or the inspector, as the case may be, must sign here</td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Signature for union or inspector………………………………………date / /Name (print): ………………………………………position: ………………………………………</td></tr><tr style="height:0pt"><td style="width:125.9pt"></td><td style="width:14.2pt"></td><td style="width:6.5pt"></td><td style="width:43.1pt"></td><td style="width:21.25pt"></td><td style="width:77.95pt"></td><td style="width:70.5pt"></td></tr></tbody></table> ``` U No \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | FEE [Section 170CEAA of the Workplace Relations Act 1996 requires a fee of $52.40 to be paid on lodgment of this application in the Commission unless a Registrar has approved the waiving of the fee (in which case a copy of the Registrar’s approval should accompany this application). If an application is lodged by facsimile transmission the credit card details must be provided] cash cheque/money order (to be made payable to Collector of Public Monies, Australian Industrial Registry) Bankcard  Visa  MastercardCard Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Card Expiry Date ____ / ____Cardholder’s Name ________________________________________Normal Card Signature _____________________________________In the event of a refund of the lodging fee being applicable, the refund should be forwarded to:…………………………………………………………………………………………………………………………………………………………………………………… | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | Commission Use Only ## Receipt Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_/Credit Transaction ## Processed\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Form R20 Application for relief in respect of termination of employment (rule 37) | Australian Industrial Relations CommissionApplication for relief in respect of termination of employment | Commission use onlyfile number | | -------------------------------------------------------------------------------------------------------- | ------------------------------ | | Workplace Relations Act 1996 (Cth)Subsection 170CE (3) | date received | This Form is to be completed in respect of an application to the Commission for relief in respect of termination of employment solely on the ground or grounds of an alleged contravention of one or more of sections 170CK, 170CM and 170CN of the Workplace Relations Act 1996. In making this claim the applicant union (being a trade union whose rules entitle it to represent the industrial interests of the employee) should be aware that: - specified categories of employees are excluded from making a claim under the Termination of Employment provisions of the Workplace Relations Act 1996. - section 170CJ of the Workplace Relations Act 1996 allows, in certain circumstances, the Commission to make an order for costs - Section 170CEAA of the Workplace Relations Act 1996 requires a fee of $52.40 to be paid on lodgment of this application in the Commission unless a Registrar has approved the waiving of the fee. The $52.40 lodgment fee is refundable under certain circumstances Details in relation to these matters are available from the Industrial Registry. Application is made by— | Name of union making application | | | ---------------------------------------------------- | -------------------------------------------------------------------------------------------------- | | address of union | …………………………………………………………………………………………………………………………………………. Postcode: ……Phone (….) …………………. Fax (…..) …… | | union contact person for notices from the Commission | | The application is made on behalf of the following employee/s ```html <table cellspacing="0" cellpadding="0" style="width:360.15pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Name/s of employee/s (or attached)</td></tr><tr><td colspan="2" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#d8d8d8">Grounds for application</td></tr><tr><td colspan="2" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Identify the ground or grounds under subsection 170CE (3) of the Workplace Relations Act 1996 upon which this application is based—on the ground or grounds of an alleged contravention of one or more of—section 170CK ; and/ orsection 170CM ; and/ orsection 170CN </td></tr><tr><td colspan="2" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Details of employer</td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">employer’s namecontact person</td><td style="width:243.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">……………………………………………………………………………………………………………………… ……</td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">employer’s trading address or registered office</td><td style="width:243.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">………………………………………………………………………………………………………………………………………………………………….. Postcode ……………Phone (…) …………………….. Fax (….) ……………</td></tr><tr><td style="width:93.85pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">date/s of termination of employee/s employment</td><td style="width:243.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">/ /</td></tr></tbody></table> ``` ```html <table cellspacing="0" cellpadding="0" style="width:360.15pt; border-collapse:collapse"><tbody><tr><td style="width:93.85pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">other employment details</td><td colspan="4" style="width:243.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">State the name of the award or agreement (including Australian Workplace Agreement) under which the employee/s were employed immediately prior to the termination/s………………………………………………………………</td></tr><tr><td style="width:93.85pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="4" style="width:243.95pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">State whether the award or agreement is State or Federal Federal  State If State, name of State: …………………………</td></tr><tr><td colspan="5" style="width:348.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Relief Sought</td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Identify the type of relief being sought</td><td colspan="2" style="width:75.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"> reinstatement</td><td style="width:73.2pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"> compensation</td><td style="width:73.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"> other—give details</td></tr><tr><td colspan="5" style="width:348.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e5e5e5">Declaration</td></tr><tr><td colspan="5" style="width:348.6pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">I declare that all the facts in this application are correct and complete to the best of my knowledge and belief.</td></tr><tr><td colspan="2" style="width:165pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Union representative must sign here</td><td colspan="3" style="width:172.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">……………………………………………Date / /Name (print) ……………………………………………Position ……………………………………………</td></tr><tr style="height:0pt"><td style="width:104.65pt"></td><td style="width:71.15pt"></td><td style="width:15.6pt"></td><td style="width:84pt"></td><td style="width:84pt"></td></tr></tbody></table> ``` U No \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | FEE [Section 170CEAA of the Workplace Relations Act 1996 requires a fee of $52.40 to be paid on lodgment of this application in the Commission unless a Registrar has approved the waiving of the fee (in which case a copy of the Registrar’s approval should accompany this application). If an application is lodged by facsimile transmission the credit card details must be provided] cash cheque/money order (to be made payable to Collector of Public Monies, Australian Industrial Registry) Bankcard  Visa  MastercardCard Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Card Expiry Date ____ / ____Cardholder’s Name_________________________________________Normal Card Signature ______________________________________In the event of a refund of the lodging fee being applicable, the refund should be forwarded to:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… | | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | Commission Use Only ## Receipt Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_/Credit Transaction ## Processed\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Form R21 Notice of employer’s appearance — termination of employment (rule 38) ```html <table cellspacing="0" cellpadding="0" style="width:347.65pt; margin-left:6.98pt; border-collapse:collapse"><tbody><tr><td rowspan="2" style="width:186.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top">Australian Industrial Relations CommissionNotice of Employer’s appearance — termination of employmentWorkplace Relations Act 1996 (Commonwealth)Section 170CE</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Commission use onlyFile number:</td></tr><tr><td style="width:139.3pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Date received:</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Please place a tick or cross, where necessary, in the boxes below.</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Application details (as stated in Form R18)</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">1 Former employee’s full name as appearing on Form R18</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top"></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">2 Commission Case/ File Number</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">U</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Details of employer</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">3 Employer named on application</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top"></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">4 Has the applicant given the employer's correct name?</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">Yes  No  If no, correct name is</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">5 Employer’s address</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">Postcode:</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">6 Details of contact person</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">[first name] [family name]Phone ( )Fax ( )Mobile</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">7 Employer’s details</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top"> CompanyACN _______________ Partnership Sole trader Government Authority Other (specify)</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">8 Was the employer named in item 3 or 4 above the employer of the applicant at the time of termination?</td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"> Yes  NoIf no, what was the name and address of employer at time of termination?</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">9 Was the applicant employed under an award or agreement (including an Australian Workplace Agreement) immediately before the termination?</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top"> Yes  NoIf yes, was it:Federal  or State If State, which State?</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Details of employer’s representative</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">10 Is anyone representing the employer?</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">Yes  go to item 11No  go to item 14</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">11 Name of solicitor, legal firm, employer organisation or other representative</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top"></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">12 Contact details of solicitor, legal firm, employer organisation or other representative</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">[first name] [family name]Phone ( )Fax ( )Mobile</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">13 Address of solicitor, legal firm, employer organisation or other representative</td><td style="width:139.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">Postcode:</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Address for notices</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">14 Where does the employer want notices to be sent?</td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Business address or address of solicitor, employer organisation or other representative Choose only one option</td></tr><tr><td colspan="2" style="width:336.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Reasons for termination</td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">15 Brief summary of reason(s) given to employee for termination</td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Write here or attach document</td></tr><tr><td colspan="2" style="width:336.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Late lodgment objection (if applicable)</td></tr><tr><td colspan="2" style="width:336.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">16 If the application was lodged in the Commission more than 21 days after the day on which the termination took effect, the Commission must decide whether to accept the application.If the application was lodged out of time, please indicate whether the employer objects to the Commission extending the time for lodgment.</td></tr><tr><td colspan="2" style="width:336.2pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"> I object to the Commission extending the time for lodgment and also object to conciliation before determination of the application to extend time; OR</td></tr><tr><td colspan="2" style="width:336.2pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"> I object to the Commission extending the time for lodgment but do not object to conciliation before determination of the application to extend time; OR</td></tr><tr><td colspan="2" style="width:336.2pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"> I do not object to the Commission extending the time for lodgment.</td></tr></tbody></table> ``` ```html <table cellspacing="0" cellpadding="0" style="width:347.65pt; margin-left:6.85pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:336.2pt; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Dismissal for want of jurisdiction (if applicable)</td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Note If the employer intends to move for the dismissal of the application for want of jurisdiction, Form R21A must be completed and filed.</td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">ExamplesExamples of jurisdictional grounds on which an employer may move for the dismissal of the application (see sections 170CBA, 170CC and subsection 170CE (5A) Workplace Relations Act 1996 are as follows:</td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin-top:1pt; margin-left:27.6pt; margin-bottom:3pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant had not completed the qualifying period of employment (see subsection 170CE (5A)).</li></ul></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin-top:1pt; margin-left:27.6pt; margin-bottom:3pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant was engaged under a contract of employment for a specified period of time (see paragraph 170CBA (1) (a)).</li></ul></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li class="FootnoteText" style="margin-top:1pt; margin-left:27.6pt; margin-bottom:3pt; text-align:justify; padding-left:8.4pt; font-family:serif">The applicant was engaged under a contract of employment for a specified task (see paragraph 170CBA (1) (b)).</li></ul></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin-left:27.6pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant was serving a period of probation, the duration or maximum duration of which was determined in advance and was 3 months or less, or otherwise reasonable given the nature and circumstances of the employment (see paragraph 170CBA (1) (c)).</li><li style="margin-right:0.3pt; margin-left:27.6pt; margin-bottom:3pt; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant was a casual employee engaged for a short period.</li></ul>A casual employee is taken to be engaged for a short period unless:(a) (i) the employee is engaged by a particular employer on a regular and systematic basis for a sequence of periods of employment during a period of at least 12 months; or(ii) the employee was engaged on a regular and systematic basis for a sequence of periods during a period of employment totalling at least 12 months but ceased to be so engaged, on the employer’s initiative, at the end of the first period of employment of less than 12 months, and then within 3 months after the end of the first period was engaged again for a further sequence of periods of employment; and(b) the employee has, or but for a decision by the employer to terminate the employee’s employment, would have had, a reasonable expectation of continuing employment by the employer.(see paragraph 170CBA (1) (d), subsections 170CBA (3) and (3A)).</td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin-right:1.7pt; margin-left:28.2pt; text-align:justify; padding-left:8.35pt; font-family:serif; font-size:10pt">The applicant was a trainee employed under a traineeship agreement or an approved traineeship for a specified period, or for the duration of the agreement (see paragraph 170CBA (1) (e)).</li></ul></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin:1pt 1.7pt 3pt 28.25pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant was not employed under award conditions and the applicant’s annual remuneration immediately before termination exceeded a specified rate ($94 900, July 2005) (see paragraph 170CBA (1) (f)).</li></ul></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li style="margin:1pt 1.7pt 4pt 28.25pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-size:10pt">The applicant is not covered by a federal award or agreement.</li></ul>(This may be a relevant objection only in NSW, Qld, WA, SA, Tas. This basis of objection is only applicable if the application is based on the ground that the termination was harsh, unjust or unreasonable.)</td></tr><tr><td colspan="2" style="width:336.2pt; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li class="note0" style="margin:1pt 1.7pt 4pt 29.35pt; text-align:justify; padding-left:8.4pt; font-family:serif; font-style:normal">The employer is not a constitutional corporation.</li></ul>(This may be a relevant objection only in NSW, Qld, WA, SA, Tas. This ground of objection is applicable only if the application is based on the ground that the termination was harsh, unjust or unreasonable.)</td></tr><tr><td colspan="2" style="width:336.2pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Declaration</td></tr><tr><td colspan="2" style="width:336.2pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">I declare that all the facts in this notice are correct and complete to the best of my knowledge and belief.</td></tr><tr><td rowspan="2" style="width:109.8pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">The employer must sign this declaration unless the application was prepared by a solicitor, employer organisation or other representative of the employer.</td><td style="width:215.7pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">[signature of employer]Date / /</td></tr><tr><td style="width:215.7pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">[signature of solicitor, employer organisation or other representative]Date / /</td></tr></tbody></table> ``` If this notice was prepared by a legal practitioner, has a contingency fee agreement (see section 170CIA) been entered into? Yes  No  If this notice was prepared by a representative other than a legal practitioner, has a costs arrangement (see section 170CIA) been entered into? Yes  No  Note This form must be lodged with the Commission within 7 days of receipt of the application (Form R18). Immediately after lodging the form, the employer must give a copy of the form to the applicant personally, or by post or facsimile transmission, at his or her address for service. PLEASE RETAIN A COPY OF THIS DOCUMENT FOR YOUR OWN RECORDS Form R21A Motion to dismiss the application for want of jurisdiction (rule 38) ```html <table cellspacing="0" cellpadding="0" style="width:360.1pt; border-collapse:collapse"><tbody><tr><td colspan="3" rowspan="2" style="width:214.4pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Australian Industrial Relations CommissionMotion to dismiss the application for want of jurisdictionWorkplace Relations Act 1996 (Cwlth)Section 170CEA</td><td style="width:123.55pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Commission use onlyFile number:</td></tr><tr><td style="width:123.55pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Date received:</td></tr><tr><td colspan="4" style="width:348.65pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">Commission CaseFile Number U</td></tr><tr><td colspan="4" style="width:348.65pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Dismissal for want of jurisdictionPlease place a tick or cross, where necessary, in the boxes below</td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"></td><td colspan="3" style="width:314.95pt; border-right:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">The respondent moves for the dismissal of the application for want of jurisdiction before the matter is referred for conciliation; OR</td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"></td><td colspan="3" style="width:314.95pt; border-right:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">The respondent moves for the dismissal of the application for want of jurisdiction but indicates that the motion may be dealt with after the matter is referred for conciliation; OR</td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"></td><td colspan="3" style="width:314.95pt; border-right:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">The respondent moves (not having previously so moved) for the dismissal of the application for want of jurisdiction as conciliation has not resulted in settlement of this matter; OR</td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"></td><td colspan="3" style="width:314.95pt; border-right:0.75pt solid #000000; padding-right:4.97pt; padding-left:5.35pt; vertical-align:top">The respondent moves (having previously so moved) for the dismissal of the application for want of jurisdiction.</td></tr><tr><td colspan="4" style="width:348.65pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">The respondent moves for the dismissal of the application on the following grounds:Note See Form R21 for some examples of jurisdictional grounds on which an employer may move for the dismissal of the application.Documentation that will be relied on to substantiate the jurisdictional objection must accompany this Notice.</td></tr><tr><td colspan="4" style="width:348.65pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2">Declaration</td></tr><tr><td colspan="4" style="width:348.65pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">I declare that all the facts in this notice are correct and complete to the best of my knowledge and belief.</td></tr><tr><td colspan="2" rowspan="2" style="width:122.25pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">The respondent must sign this notice unless a solicitor, legal firm, employer organisation or other representative has prepared the notice.</td><td colspan="2" style="width:215.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">[signature of respondent]Date / /</td></tr><tr><td colspan="2" style="width:215.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top">[signature of solicitor, legal firm, employer organisation or other representative]Date / /</td></tr><tr style="height:0pt"><td style="width:33.7pt"></td><td style="width:99.25pt"></td><td style="width:92.15pt"></td><td style="width:134.25pt"></td></tr></tbody></table> ``` > Note A motion to dismiss the application for want of jurisdiction is deemed to be made on the date of filing. Immediately after filing the motion, the employer must give a copy of the motion to the applicant personally, or by post or facsimile transmission, at his or her address for service. PLEASE RETAIN A COPY OF THIS DOCUMENT FOR YOUR OWN RECORDS Form R22 Notice of representative’s appearance (rule 39) Workplace Relations Act 1996 ## AUSTRALIAN INDUSTRIAL RELATIONS COMMISSION ## NOTICE OF REPRESENTATIVE’S APPEARANCE 1. Title of Matter: ............…………...................................................................................………… U No. .............................................. 2. Name of solicitor or other representative entering appearance\*/change of appearance\* ………...................................................................................................………… 3. Address for service of solicitor or representative ........................................................................................................……….…….. ........................................................................................................……………... ................................……….....…….............Facsimile:…....................……….... 4. Appearance is entered on behalf of applicant\*/respondent\*. 5. I/We have been retained by the party under a costs arrangement or a contingency fee agreement  Yes  No 6. Signature of solicitor or representative....…...……......................………. 7. Date of this Notice ...............................………….…………….…….…... \* Omit whichever is inapplicable. > Note Immediately after filing the notice, a copy must be given to the other party at his or her address for service either personally, or by post or facsimile transmission. Form R23 Notice of discontinuance (rule 43) Workplace Relations Act 1996 AUSTRALIAN INDUSTRIAL RELATIONS COMMISSION NOTICE OF DISCONTINUANCE Commission Reference U ................................................................ In the matter of \[name of employee\] and \[name of employer\] The Applicant \*wholly discontinues this matter \*wholly discontinues this matter as part of the terms of settlement agreed to. Dated: ....................................................... Signed: ...................................................................................... \[applicant/solicitor/union or other representative\] \* Omit whichever is inapplicable. NOTE: AFTER FILING THIS NOTICE IN THE INDUSTRIAL REGISTRY A COPY OF THIS NOTICE MUST BE GIVEN IMMEDIATELY TO THE EMPLOYER AT HIS OR HER ADDRESS FOR SERVICE EITHER PERSONALLY, BY POST OR FACSIMILE TRANSMISSION. | Commission use only:Date Received: | | ---------------------------------- | Form R24 Certificate under section 170CF (rule 44) Workplace Relations Act 1996 ## AUSTRALIAN INDUSTRIAL RELATIONS COMMISSION CERTIFICATE STATING COMMISSION IS SATISFIED CONCILIATION UNSUCCESSFUL ## (U No ..............................................) \[name of member\] \[place and date\] An application for relief in respect of termination of employment has been lodged on the following ground or grounds:  the termination was harsh, unjust or unreasonable  an alleged contravention of section 170CK of the Act  an alleged contravention of section 170CL of the Act  an alleged contravention of section 170CM of the Act  an alleged contravention of section 170CN of the Act In accordance with subsection 170CF (2) of the Workplace Relations Act 1996, the Commission certifies that all reasonable attempts to settle the matter by conciliation have been, or are likely to be, unsuccessful in respect of the following ground or grounds:  the termination was harsh, unjust or unreasonable  an alleged contravention of section 170CK of the Act  an alleged contravention of section 170CL of the Act  an alleged contravention of section 170CM of the Act  an alleged contravention of section 170CN of the Act An assessment of the merits of the application has been indicated to the parties in the following terms: \[set out terms of assessment\] The Commission recommends that the applicant not pursue the application\* AND/OR Having regard to all the material before the Commission, the Commission concludes under subsection 170CF (4) that the applicant has no reasonable prospect of success at arbitration in relation to the ground that the termination was harsh, unjust or unreasonable.\]\* \* Omit if inapplicable BY THE COMMISSION: \[Signature of member\] Member’s Title > Note The applicant has 7 days from the date of this certificate within which to lodge a notice of election.