CTHRepealedLegislation
Australian Industrial Relations Commission Rules 1998
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"><p style="margin-top:3pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Australian Industrial Relations Commission</span></p><p class="FormHeading" style="margin-top:9pt; text-align:left; font-size:10pt"><span>Application for relief in respect of termination of employment</span></p></td><td style="width:103.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Commission use only</span></p><p style="margin-top:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">file number</span></p></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"><p style="margin-top:3pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">Workplace Relations Act 1996</span><span style="font-family:Arial, sans-serif"> (Cth)</span></p><p style="margin-top:6pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Subsection</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">170CE</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(2) or (4)</span></p></td><td style="width:103.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">date received</span></p></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"><p style="font-size:10pt"><span style="font-weight:bold">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</span><span style="font-weight:bold"> </span><span style="font-weight:bold">170CL of the</span><span style="font-weight:bold; font-style:italic"> Workplace Relations Act 1996.</span></p><p><span></span></p><p style="margin-right:93.85pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Section 170CL states:</span></p><p class="R1" style="margin-bottom:6pt"><span style="width:23.6pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">“(1)</span><span style="width:8.5pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">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.</span></p><p class="R1" style="margin-bottom:3pt"><span style="width:28.04pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">(2)</span><span style="width:8.5pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">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:</span></p><p class="P1" style="margin-bottom:3pt"><span style="font-size:10pt"></span><span style="width:45.95pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">(a)</span><span style="width:11.35pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">the reasons for the terminations; and</span></p><p class="P1" style="margin-bottom:3pt"><span style="width:47.89pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">(b)</span><span style="width:11.35pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">the number and categories of employees likely to be affected; and</span></p><p class="P1" style="margin-bottom:3pt"><span style="width:48.45pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">(c)</span><span style="width:11.35pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">the time when, or the period over which, the employer intends to carry out the terminations.</span></p><p class="P1"><span style="width:47.89pt; text-indent:0pt; font-size:10pt; display:inline-block"></span><span style="font-size:10pt">(3)</span><span style="width:11.35pt; text-indent:0pt; font-size:10pt; display:inline-block"> </span><span style="font-size:10pt">The employer must not terminate an employee’s employment pursuant to the decision unless the employer has complied with subsection (2).”.</span></p></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"><p style="margin-top:3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Details of employer alleged to have contravened section 170CL</span></p></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"><p style="margin:3pt 1.15pt 15pt 17pt; text-indent:-17pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">1</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">employer’s name</span></p><p style="margin-top:15pt; margin-right:1.15pt; margin-left:17pt; text-indent:-17pt; page-break-after:avoid; font-size:10pt"><span style="width:17pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">contact person</span></p></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-left:151.1pt; margin-bottom:15pt; text-indent:-151.1pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p><p style="margin-top:15pt; margin-left:151.1pt; text-indent:-151.1pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p></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"><p style="margin-top:3pt; margin-right:1.15pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">2</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">employer’s trading address or registered office</span></p></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:12pt; margin-left:151.1pt; margin-bottom:3pt; text-indent:-148.85pt; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p><p style="margin-top:3pt; margin-left:151.1pt; margin-bottom:3pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………… ……..</span></p><p style="margin-top:3pt; margin-left:115.25pt; margin-bottom:3pt; text-indent:-113.05pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………… Postcode …………</span></p><p style="margin-top:3pt; margin-left:151.1pt; text-indent:-148.85pt; font-size:10pt"><span style="font-family:Arial, sans-serif">phone (….) ………………… Fax (….) ………</span></p></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"><p style="margin-top:3pt; margin-right:1.15pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">3</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">date notice of decision to terminate employee’s employment was given.</span></p></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:18pt; margin-left:151.1pt; margin-bottom:3pt; text-indent:-148.85pt; font-size:10pt"><span style="width:42.15pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"></span><span style="font-family:Arial, sans-serif; font-weight:bold">/</span><span style="width:39.72pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-weight:bold">/</span></p><p style="margin-top:3pt; margin-left:151.1pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-right:1.15pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">4</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"> </span><span style="font-family:Arial, sans-serif">other employment details</span></p></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="BodyTextIndent" style="margin-top:3pt; margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif">State the name of the award or agreement (including Australian Workplace Agreement) under which the employees are*/ were employed</span></p><p class="BodyTextIndent" style="margin-top:6pt; margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p></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"><p style="margin-top:3pt; margin-right:1.15pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></td><td colspan="5" style="width:208.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0.55pt; font-size:10pt"><span style="font-family:Arial, sans-serif">State whether the award or agreement is State or Federal</span></p><p style="margin-top:3pt; margin-left:22.95pt; margin-bottom:3pt; text-indent:-20.75pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="width:11.84pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">Federal</span></p><p style="margin-top:3pt; margin-left:22.95pt; text-indent:-20.75pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="width:11.84pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">State If State, name of State: …………</span></p></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"><p style="margin-left:17pt; text-indent:-17pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">5</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-weight:bold">About the employees</span></p></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"><p class="BodyText" style="margin-bottom:18pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Here insert name and address of employee/s whose employment has been* / is proposed to be* terminated by the employer</span></p><p style="margin-top:18pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">6</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-weight:bold">Brief summary of reasons given for termination or threatened termination</span><br><span style="font-family:Arial, sans-serif; font-style:italic">(or attached)</span></p><p class="BodyText" style="font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p style="margin-top:6pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p class="DefaultParagraphFont1" style="font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………………………………………………</span></p></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"><p style="page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Extension of Time</span></p></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"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p style="text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif">7</span><span style="width:30.44pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">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:</span><span style="font-family:Arial, sans-serif; font-style:italic">(or attached)</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic"></span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="page-break-after:avoid; font-size:10pt"><a id="_Toc108855926"><span style="font-family:Arial, sans-serif; font-weight:bold">Details of Union</span></a></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">8</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">Is your union acting on your behalf</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">No </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> go to 11</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Yes </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> go to 9</span></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">9</span><span style="width:11.44pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">name and address of union</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:12pt; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">……………………….. Postcode</span></p></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"><p style="margin-top:3pt; margin-left:17pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">10</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">union contact person</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="BodyText" style="margin-top:12pt; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………</span></p><p style="margin-top:6pt; font-size:10pt"><span style="font-family:Arial, sans-serif">phone (…..) …………… Fax (…..) …………</span></p></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"><p style="page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Details of representative</span></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">11</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">Is anyone representing you?</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">No </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> go to 15</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Yes </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> go to 12</span></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">12</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">name of solicitor or representative’s firm</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">13</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">name of contact person</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:6pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">14</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">address</span></p></td><td colspan="4" style="width:202pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:12pt; margin-left:151.1pt; margin-bottom:3pt; text-indent:-148.85pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………………</span></p><p style="margin-top:3pt; margin-left:151.1pt; margin-bottom:3pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">…………………………………………… ……..</span></p><p style="margin-top:3pt; margin-left:115.25pt; margin-bottom:3pt; text-indent:-113.05pt; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………… Postcode …………</span></p><p style="margin-top:3pt; margin-left:151.1pt; text-indent:-148.85pt; font-size:10pt"><span style="font-family:Arial, sans-serif">phone (….) ………………… Fax (….) ………</span></p></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"><p style="margin-top:3pt; margin-bottom:2pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Notices from the Commission</span></p></td></tr><tr><td style="width:115.1pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-left:17pt; margin-bottom:3pt; text-indent:-17pt; font-size:10pt"><span style="font-family:Arial, sans-serif">15</span><span style="width:5.88pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">Where do you want notices from the Commission sent?</span></p><p style="margin-top:3pt; margin-left:14.2pt; text-indent:-14.2pt; font-size:10pt"><span style="width:14.2pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">(choose one only)</span></p></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"><p style="margin-top:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">address in 5 </span><span style="font-family:Wingdings, serif"></span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">union in 9 </span><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:3pt; border-right:0.75pt solid #000000; padding-right:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">other in 12 </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> give details</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-bottom:2pt; page-break-before:always"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Declaration</span></p></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"><p style="margin-bottom:6pt; text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold"></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:justify; font-size:10pt"><span style="height:0pt; margin-top:-6pt; text-align:left; display:block; position:relative; z-index:1"><img src="image.003.png" width="2" height="2" alt="" style="margin-top:-40.3pt; margin-left:122.6pt; position:absolute"></span><span style="font-family:Arial, sans-serif; font-weight:bold">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 </span><span style="font-family:Arial, sans-serif; font-weight:bold; font-style:italic">Workplace Relations Act 1996</span><span style="font-family:Arial, sans-serif; font-weight:bold"> or under any other law of the Commonwealth or of a State or Territory.</span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">I further declare that all the facts in this application are correct and complete to the best of my knowledge and belief.</span></p></td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="note0" style="margin-top:3pt; margin-bottom:0pt"><span style="font-family:Arial, sans-serif">The employee must sign this declaration*</span></p></td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Signature of employee</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">date</span><span style="width:74.34pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span><span style="width:39.77pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span></p></td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">If a solicitor or authorised representative has prepared the application, that person must sign here</span></p></td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Signature of solicitor or representative</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">date</span><span style="width:74.34pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span><span style="width:39.77pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span></p></td></tr><tr><td colspan="4" style="width:178.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">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</span></p></td><td colspan="3" style="width:158.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Signature for union or inspector</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">date</span><span style="width:74.34pt; font-family:Arial, sans-serif; font-style:italic; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span><span style="width:39.77pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">Name (print): ………………………………………</span></p><p style="font-size:10pt"><span style="font-family:Arial, sans-serif">position: ………………………………………</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Name/s of employee/s (or attached)</span></p><p style="margin-top:9pt; margin-right:0.3pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:9pt; margin-right:0.3pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Grounds for application</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Identify the ground or grounds under subsection</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">170CE</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(3) of the </span><span style="font-family:Arial, sans-serif; font-style:italic">Workplace Relations Act 1996</span><span style="font-family:Arial, sans-serif"> upon which this application is based—</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">on the ground or grounds of an alleged contravention of one or more of—</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">section</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">170CK </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif">; and/ or</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">section</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">170CM </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif">; and/ or</span></p><p style="margin-top:3pt; margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">section</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">170CN </span><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Details of employer</span></p></td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:12pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">employer’s name</span></p><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">contact person</span></p></td><td style="width:243.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin:12pt 0.3pt 3pt 151.1pt; text-indent:-151.1pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………………………………</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-left:151.1pt; text-indent:-151.1pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">……………………………………………………… ……</span></p></td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">employer’s trading address or registered office</span></p></td><td style="width:243.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin:12pt 0.3pt 3pt 151.1pt; text-indent:-148.85pt; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………………………………</span></p><p style="margin:3pt 0.15pt 3pt 151.1pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………………………………</span></p><p style="margin:3pt 0.15pt 3pt 151.1pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………….. Postcode ……………</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-left:151.1pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Phone (…) …………………….. Fax (….) ……………</span></p></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"><p style="margin-top:3pt; margin-right:0.15pt; font-size:10pt"><span style="font-family:Arial, sans-serif">date/s of termination of employee/s employment</span></p></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"><p style="margin:18pt 0.3pt 3pt 151.1pt; text-indent:-148.85pt; font-size:10pt"><span style="width:49.05pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"></span><span style="font-family:Arial, sans-serif; font-weight:bold">/</span><span style="width:39.72pt; text-indent:0pt; font-family:Arial, sans-serif; font-weight:bold; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-weight:bold">/</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-left:151.1pt; text-indent:-148.9pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">other employment details</span></p></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"><p class="BlockText" style="margin-left:0pt; margin-bottom:18pt; font-size:10pt"><span style="font-family:Arial, sans-serif">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</span></p><p style="margin-top:18pt; margin-right:0.3pt; margin-left:1.7pt; font-size:10pt"><span style="font-family:Arial, sans-serif">………………………………………………………………</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p style="margin:3pt 0.3pt 3pt 1.7pt; font-size:10pt"><span style="font-family:Arial, sans-serif">State whether the award or agreement is State or Federal</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-left:1.7pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Federal </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> State If State, name of State: …………………………</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Relief Sought</span></p></td></tr><tr><td style="width:93.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.15pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">Identify the type of relief being sought</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:'Monotype Sorts', serif"></span><span style="font-family:Arial, sans-serif"> reinstatement</span></p></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"><p style="margin-top:3pt; margin-right:0.3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> compensation</span></p></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"><p style="margin-right:0.3pt; margin-bottom:30pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> other—give details</span></p></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"><p style="margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Declaration</span></p></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"><p style="margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">I declare that all the facts in this application are correct and complete to the best of my knowledge and belief.</span></p></td></tr><tr><td colspan="2" style="width:165pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">Union representative must sign here</span></p></td><td colspan="3" style="width:172.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-right:0.3pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">……………………………………………</span></p><p style="margin-top:5pt; margin-right:0.15pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Date</span><span style="width:72.43pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span><span style="width:39.72pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">/</span></p><p style="margin-top:5pt; margin-right:0.3pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Name (print) ……………………………………………</span></p><p style="margin-top:5pt; margin-right:0.3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Position ……………………………………………</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:0pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Australian Industrial Relations Commission</span></p><p class="FormHeading" style="margin-top:4pt; margin-bottom:4pt; text-align:left"><span style="text-transform:none">Notice of Employer’s appearance — termination of employment</span></p><p style="margin-top:4pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">Workplace Relations Act 1996 </span><span style="font-family:Arial, sans-serif">(Commonwealth)</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:0pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Section 170CE</span></p></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"><p style="margin-bottom:1pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Commission use only</span></p><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">File number:</span></p><p style="margin-top:4pt; margin-right:0.3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold"></span></p></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"><p style="margin-top:1pt; margin-right:0.15pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Date received:</span></p></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"><p class="Schedulepara" style="margin-left:1.75pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Please place a tick or cross, where necessary, in the boxes below.</span></p></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"><p class="Schedulepara" style="margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold; font-style:italic">Application details (as stated in Form R18)</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:14.55pt; margin-bottom:3pt; text-indent:-14.55pt; text-align:left"><span style="font-family:Arial, sans-serif"></span><span style="font-family:Arial, sans-serif; font-size:10pt">1 Former employee’s full name as appearing on Form R18</span></p></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"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:3pt"><span style="font-family:Arial, sans-serif"></span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:14.55pt; margin-bottom:3pt; text-indent:-12.8pt; text-align:left"><span style="font-family:Arial, sans-serif"></span><span style="font-family:Arial, sans-serif; font-size:10pt">2 Commission Case/</span><br><span style="font-family:Arial, sans-serif; font-size:10pt">File Number</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:14.55pt; margin-bottom:3pt; text-indent:-12.8pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">U</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Details of employer</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">3</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Employer named on application</span></p></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"><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:3pt"><span style="font-family:Arial, sans-serif"></span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">4</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Has the applicant given the employer's correct name?</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Yes </span><span style="font-family:Wingdings, serif; font-size:10pt"></span><span style="font-family:Arial, sans-serif; font-size:10pt"> No </span><span style="font-family:Wingdings, serif; font-size:10pt"></span><br><span style="font-family:Arial, sans-serif; font-size:10pt">If no, correct name is</span></p><p style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">5</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Employer’s address</span></p></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"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:0.65pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Postcode:</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">6</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Details of contact person</span></p></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"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">[first name] [family name]</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Phone ( )</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Fax ( )</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Mobile</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">7</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Employer’s details</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Wingdings, serif; font-size:10pt"></span><span style="font-family:Arial, sans-serif; font-size:10pt"> Company</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">ACN _______________</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Partnership</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Sole trader</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Government Authority</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Other (specify)</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">8</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Was the employer named in item 3 or 4 above the employer of the applicant at the time of termination?</span></p></td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Yes </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> No</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">If no, what was the name and address of employer at time of termination?</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">9</span><span style="width:10.54pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Was the applicant employed under an award or agreement (including an Australian Workplace Agreement) immediately before the termination?</span></p></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"><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> Yes </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> No</span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">If yes, was it:</span><span style="width:24.26pt; font-family:Arial, sans-serif; display:inline-block"></span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Federal </span><span style="font-family:Wingdings, serif"></span><span style="font-family:Arial, sans-serif"> or</span><span style="width:24.78pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">State </span><span style="font-family:Wingdings, serif"></span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-left:1.7pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">If State, which State?</span></p></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"><p class="Schedulepara" style="margin-top:8pt; margin-left:1.7pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Details of employer’s representative</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">10</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Is anyone representing the employer?</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:4pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">Yes </span><span style="font-family:Wingdings, serif; font-size:10pt"></span><span style="font-family:Arial, sans-serif; font-size:10pt"> go to item 11</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">No </span><span style="font-family:Wingdings, serif; font-size:10pt"></span><span style="font-family:Arial, sans-serif; font-size:10pt"> go to item 14</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">11</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Name of solicitor, legal firm, employer organisation or other representative</span></p></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"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:3pt"><span style="font-family:Arial, sans-serif"></span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">12</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Contact details of solicitor, legal firm, employer organisation or other representative</span></p></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"><p style="margin-top:1pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">[first name] [family name]</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Phone ( )</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Fax ( )</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Mobile</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">13</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Address of solicitor, legal firm, employer organisation or other representative</span></p></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"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Postcode:</span></p></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"><p class="Schedulepara" style="margin-left:1.75pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Address for notices</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">14</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Where does the employer want notices to be sent?</span></p></td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif; font-size:10pt">Business address </span><span style="font-family:Wingdings, serif"></span></p><p style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif; font-size:10pt">or address of solicitor, employer organisation or other representative</span><span style="width:19.88pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Wingdings, serif"></span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Choose only one option</span></p></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"><p class="Schedulepara" style="margin-left:1.7pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Reasons for termination</span></p></td></tr><tr><td style="width:186.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">15</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Brief summary of reason(s) given to employee for termination</span></p></td><td style="width:139.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:1pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Write here or attach document</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-left:1.75pt; margin-bottom:4pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:4pt; margin-left:1.75pt; margin-bottom:3pt"><span style="font-family:Arial, sans-serif"></span></p></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"><p class="Schedulepara" style="margin-left:1.7pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Late lodgment objection (if applicable)</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:4pt; text-indent:-16.1pt"><span style="font-family:Arial, sans-serif; font-size:10pt">16</span><span style="width:4.98pt; text-indent:0pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">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.</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="width:16.15pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">If the application was lodged out of time, please indicate whether the employer objects to the Commission extending the time for lodgment.</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="width:7.24pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="width:0pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">I object to the Commission extending the time for lodgment and also object to conciliation before determination of the application to extend time; OR</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="width:7.24pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="width:0pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">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</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Wingdings, serif"></span><span style="width:7.24pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="width:0pt; text-indent:0pt; font-family:Arial, sans-serif; display:inline-block"></span><span style="font-family:Arial, sans-serif">I do not object to the Commission extending the time for lodgment.</span></p></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"><p style="margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Dismissal for want of jurisdiction (if applicable)</span></p></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">Note</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif"></span><span style="font-family:Arial, sans-serif"></span><span style="font-family:Arial, sans-serif">If the employer intends to move for the dismissal of the application for want of jurisdiction, Form R21A must be completed and filed.</span></p></td></tr><tr><td colspan="2" style="width:336.2pt; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-left:30.1pt; margin-bottom:4pt; text-indent:-30.1pt; text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">Examples</span></p><p style="margin-top:4pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif">Examples of jurisdictional grounds on which an employer may move for the dismissal of the application (see sections 170CBA, 170CC and subsection 170CE</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(5A) </span><span style="font-family:Arial, sans-serif; font-style:italic">Workplace Relations Act 1996</span><span style="font-family:Arial, sans-serif"> are as follows:</span></p></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"><span style="font-family:Arial, sans-serif">The applicant had not completed the qualifying period of employment (see subsection 170CE</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(5A)).</span></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"><span style="font-family:Arial, sans-serif">The applicant was engaged under a contract of employment for a specified period of time (see paragraph 170CBA (1)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(a)).</span></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"><span style="font-family:Arial, sans-serif">The applicant was engaged under a contract of employment for a specified task (see paragraph 170CBA</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(1)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(b)).</span></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"><span style="font-family:Arial, sans-serif">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)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(c)).</span></li><li style="margin-right:0.3pt; margin-left:27.6pt; margin-bottom:3pt; padding-left:8.4pt; font-family:serif; font-size:10pt"><span style="font-family:Arial, sans-serif">The applicant was a casual employee engaged for a short period.</span></li></ul><p style="margin-top:3pt; margin-left:38.85pt; margin-bottom:3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">A casual employee is taken to be engaged for a short period unless:</span></p><p style="margin-top:3pt; margin-left:38.85pt; margin-bottom:3pt; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">(a) (i)</span><span style="width:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">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</span></p><p style="margin-top:3pt; margin-left:38.85pt; margin-bottom:3pt; text-align:justify; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif"></span><span style="font-family:Arial, sans-serif">(ii)</span><span style="width:0pt; font-family:Arial, sans-serif; display:inline-block"> </span><span style="font-family:Arial, sans-serif">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</span></p><p style="margin-top:3pt; margin-left:38.85pt; margin-bottom:3pt; text-align:justify; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">(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.</span></p><p style="margin-top:3pt; margin-left:38.85pt; text-align:justify; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">(see paragraph 170CBA</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(1)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(d), subsections 170CBA</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(3) and (3A)).</span></p><p class="DefaultParagraphFont1" style="font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p></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"><span style="font-family:Arial, sans-serif">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</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(1)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(e)).</span></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"><span style="font-family:Arial, sans-serif">The applicant was not employed under award conditions and the applicant’s annual remuneration immediately before termination exceeded a specified rate ($94</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">900, July 2005) (see paragraph 170CBA</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(1)</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif">(f)).</span></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"><span style="font-family:Arial, sans-serif">The applicant is not covered by a federal award or agreement.</span></li></ul><p style="margin-top:4pt; margin-left:23pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">(This may be a relevant objection only in NSW, Qld, WA, SA, Tas.</span><span style="font-family:Arial, sans-serif"> </span><span style="font-family:Arial, sans-serif; font-style:italic">This basis of objection is only applicable if the application is based on the ground that the termination was harsh, unjust or unreasonable.)</span></p></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"><span style="font-family:Arial, sans-serif">The employer is not a constitutional corporation.</span></li></ul><p class="note0" style="margin:4pt 1.7pt 3pt 23pt; text-indent:-23pt; text-align:justify"><span style="width:23pt; text-indent:0pt; font-family:Arial, sans-serif; font-style:normal; display:inline-block"></span><span style="font-family:Arial, sans-serif; font-style:normal">(</span><span style="font-family:Arial, sans-serif">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.)</span></p></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"><p style="margin-top:9pt; margin-right:14.2pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Declaration</span></p></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"><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">I declare that all the facts in this notice are correct and complete to the best of my knowledge and belief.</span></p></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"><p style="margin-top:3pt; margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic">The employer must sign this declaration unless the application was prepared by a solicitor, employer organisation or other representative of the employer.</span></p></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"><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif; font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">[</span><span style="font-family:Arial, sans-serif; font-style:italic">signature of employer</span><span style="font-family:Arial, sans-serif">]</span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-right:1.7pt; margin-left:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">Date / /</span></p></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"><p class="BlockText" style="margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif">[</span><span style="font-family:Arial, sans-serif; font-style:italic">signature of solicitor, employer organisation or other representative</span><span style="font-family:Arial, sans-serif">]</span></p><p style="margin-top:6pt; margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-family:Arial, sans-serif">Date / /</span></p></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"><p class="Schedulepara" style="margin-top:1pt; margin-left:0pt; margin-bottom:4pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">Australian Industrial Relations Commission</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:0pt; margin-bottom:4pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold">Motion to dismiss the application for want of jurisdiction</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:0pt; margin-bottom:4pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Workplace Relations Act 1996</span><span style="font-family:Arial, sans-serif; font-size:10pt"> (Cwlth)</span></p><p class="Schedulepara" style="margin-top:4pt; margin-left:0pt; margin-bottom:3pt; text-indent:0pt; text-align:left; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:10pt">Section 170CEA</span></p></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"><p style="margin-bottom:1pt; font-size:11pt"><span style="font-family:Arial, sans-serif">Commission use only</span></p><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:4pt; font-size:10pt"><span style="font-family:Arial, sans-serif">File number:</span></p><p style="margin-top:4pt; margin-right:0.3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold"></span></p></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"><p style="margin-top:1pt; margin-right:0.15pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:Arial, sans-serif">Date received:</span></p></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"><p style="margin-top:6pt; margin-bottom:6pt; font-size:11pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Commission Case</span></p><p style="margin-top:6pt; margin-bottom:6pt; font-size:11pt"><span style="font-family:Arial, sans-serif; font-weight:bold">File Number U</span></p><p style="margin-top:6pt; text-align:center; font-size:11pt"><span style="font-family:Arial, sans-serif; font-weight:bold"></span></p></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"><p style="margin:9pt 14.2pt 3pt 1.7pt; page-break-after:avoid; font-size:10pt"><span style="font-weight:bold">Dismissal for want of jurisdiction</span></p><p style="margin:3pt 14.2pt 3pt 1.7pt; page-break-after:avoid; font-size:10pt"><span style="font-style:italic">Please place a tick or cross, where necessary, in the boxes below</span></p></td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 14.15pt 3pt 1.7pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:1pt; margin-right:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span>The respondent moves for the dismissal of the application for want of jurisdiction before the matter is referred for conciliation; OR</span></p></td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 14.15pt 3pt 1.7pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:1pt; margin-right:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span>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</span></p></td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 14.15pt 3pt 1.7pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:1pt; margin-right:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span>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</span></p></td></tr><tr><td style="width:23pt; border-left:0.75pt solid #000000; padding-right:5.35pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 14.15pt 3pt 1.7pt; font-size:10pt"><span style="font-family:Wingdings, serif"></span></p></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"><p style="margin-top:1pt; margin-right:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span>The respondent moves (having previously so moved) for the dismissal of the application for want of jurisdiction.</span></p></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"><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:10pt"><span>The respondent moves for the dismissal of the application on the following grounds:</span></p><p style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-weight:bold"></span></p><p style="margin-top:3pt; margin-left:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-weight:bold"></span></p><p style="margin-top:3pt; margin-left:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-weight:bold"></span></p><p style="margin-top:3pt; margin-left:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span style="font-weight:bold"></span></p><p style="margin-top:3pt; margin-left:1.75pt; margin-bottom:1pt; text-align:justify; font-size:10pt"><span style="font-weight:bold"></span></p><p style="margin-top:1pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:10pt"><span style="font-style:italic">Note</span><span style="font-style:italic"> </span><span style="font-style:italic"></span><span style="font-style:italic"></span><span>See Form R21 for some examples of jurisdictional grounds on which an employer may move for the dismissal of the application.</span></p><p style="margin-top:6pt; margin-right:1.75pt; margin-bottom:3pt; text-align:justify; font-size:10pt"><span>Documentation that will be relied on to substantiate the jurisdictional objection must accompany this Notice.</span></p></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"><p style="margin-top:9pt; margin-right:14.2pt; page-break-after:avoid; font-size:10pt"><span style="font-weight:bold">Declaration</span></p></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"><p style="margin-top:3pt; margin-left:1.7pt; margin-bottom:6pt; font-size:10pt"><span style="font-weight:bold">I declare that all the facts in this notice are correct and complete to the best of my knowledge and belief.</span></p><p style="margin-top:6pt; margin-left:1.7pt; margin-bottom:3pt; font-size:10pt"><span></span></p></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"><p style="margin-top:3pt; margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-style:italic">The respondent must sign this notice unless a solicitor, legal firm, employer organisation or other representative has prepared the notice.</span></p></td><td colspan="2" style="width:215.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>[</span><span style="font-style:italic">signature of respondent</span><span>]</span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin-right:1.7pt; margin-left:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>Date / /</span></p></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"><p class="BlockText" style="margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:10pt"><span>[</span><span style="font-style:italic">signature of solicitor, legal firm, employer organisation or other representative</span><span>]</span></p><p style="margin-top:6pt; margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>Date / /</span></p></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.