Rule 13 of the Australian Industrial Relations Commission Rules
NOTICE OF APPEAL UNDER
SECTION 120 OR 121 OF THE ACT
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:19.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:313.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:107.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:127.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:30pt"></td><td style="width:67.85pt"></td><td style="width:118.15pt"></td><td style="width:138pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:106.15pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:106.15pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the initiating party</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:106.15pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:94pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="4" style="width:238.4pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:94pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Street Address</span></p></td><td colspan="4" style="width:238.4pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:2pt; margin-bottom:4pt"><span></span></p><p style="margin-top:4pt; margin-bottom:2pt"><span></span></p></td></tr><tr><td colspan="3" style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:193.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No: [</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:193.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:139.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address: [</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:193.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:90pt"></td><td style="width:14.8pt"></td><td style="width:45.2pt"></td><td style="width:30pt"></td><td style="width:84pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the initiating party</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:89.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:145.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:100.15pt"></td><td style="width:156pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:106.15pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:101.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="2" style="width:231.3pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:101.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:231.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:101.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:231.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:101.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:231.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:101.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if</span><span style="font-style:italic"> </span><span style="font-style:italic">known</span><span>]</span></p></td><td style="width:81.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td></tr><tr><td style="width:101.1pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if</span><span style="font-style:italic"> </span><span style="font-style:italic">known</span><span>]</span></p></td><td colspan="2" style="width:231.3pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Address</span></p><p><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:89.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:145.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:73.85pt"></td><td style="width:100.15pt"></td><td style="width:156pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:80.6pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="4" style="width:251.8pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:80.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Address</span></p><p><span></span></p></td><td colspan="4" style="width:251.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:80.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="4" style="width:251.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:11.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:321.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="3" style="width:101.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:230.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="3" style="width:101.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="2" style="width:74.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td><td style="width:145.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Mobile No:</span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td></tr><tr><td colspan="4" style="width:133.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="2" style="width:199.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr style="height:0pt"><td style="width:22pt"></td><td style="width:69.4pt"></td><td style="width:21.1pt"></td><td style="width:31.5pt"></td><td style="width:54pt"></td><td style="width:156pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of notifier:</span></p></td><td colspan="2" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Address</span></p><p><span></span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the notifier</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="2" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:79.85pt"></td><td style="width:106.15pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:87.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:245.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Address for service</span></p></td><td colspan="2" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant(s)</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:245.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:95.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:87.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:245.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:79.85pt"></td><td style="width:10.15pt"></td><td style="width:96pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:47.75pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="4" style="width:284.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:47.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:284.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:133.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="2" style="width:199.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td colspan="2" style="width:103.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:229.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:103.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:139.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td></tr><tr><td colspan="3" style="width:133.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="2" style="width:199.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:58.55pt"></td><td style="width:55.45pt"></td><td style="width:30pt"></td><td style="width:60pt"></td><td style="width:150pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:85.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:247.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:85.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:247.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:49.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="4" style="width:283.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:283.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:133.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"> </span><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:199.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td colspan="2" style="width:133.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:199.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:133.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span><br><span>[</span><span style="font-style:italic">if known</span><span>]</span></p></td><td style="width:43.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:133.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address: [</span><span style="font-style:italic">if known</span><span>]</span></p></td><td colspan="3" style="width:199.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:60pt"></td><td style="width:84pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:54pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:90pt"></td><td style="width:78pt"></td><td style="width:72pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="3" style="width:451pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span>This application relates to a protected action ballot order made by [</span><span style="font-style:italic">insert name of the member who made the order</span><span>]</span></p></td></tr><tr><td style="width:80.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>on [</span><span style="font-style:italic">insert date</span><span>]</span></p></td><td style="width:358.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>in [PR [</span><span style="font-style:italic">insert print number of order</span><span>]</span><span style="font-style:italic"> </span><span>] (‘the Ballot Order’),</span></p><p><span></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:0pt"><td style="width:78.35pt"></td><td style="width:285.85pt"></td><td style="width:0.95pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:90pt"></td><td style="width:90pt"></td><td style="width:78pt"></td><td style="width:78pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="3" style="width:451pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span>This application relates to a protected action ballot order made by [</span><span style="font-style:italic">insert name of the member who made the order</span><span>]</span></p><p style="page-break-after:avoid"><span></span></p></td></tr><tr><td style="width:80.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>on [</span><span style="font-style:italic">insert date</span><span>]</span></p><p><span></span></p></td><td style="width:358.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>in [PR [</span><span style="font-style:italic">insert print number of order</span><span>]</span><span style="font-style:italic"> </span><span>] (‘the Ballot Order’),</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:0pt"><td style="width:78.35pt"></td><td style="width:285.85pt"></td><td style="width:0.95pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:90pt"></td><td style="width:96pt"></td><td style="width:72pt"></td><td style="width:78pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:1.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant/s</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:12pt"></td><td style="width:96pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:1.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:12pt"></td><td style="width:96pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:117.45pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of the applicant: [</span><span style="font-style:italic">employer, employee or organisation bound</span><span>]</span></p></td><td colspan="3" style="width:223.5pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:105.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:105.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:9.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:105.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:105.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td colspan="2" style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:105.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="4" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:20.55pt"></td><td style="width:96pt"></td><td style="width:11.7pt"></td><td style="width:72.3pt"></td><td style="width:72pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:109.85pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant:</span></p></td><td colspan="3" style="width:222.55pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td colspan="2" style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="4" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:90pt"></td><td style="width:12.65pt"></td><td style="width:65.35pt"></td><td style="width:72pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:116.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant:</span></p><p><span>[</span><span style="font-style:italic">transitional employer, transitional employees or party to the industrial dispute</span><span>]</span></p></td><td colspan="3" style="width:224.9pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:116.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:224.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:116.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:224.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:3.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:337.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:116.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:224.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:116.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:80.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:116.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:224.9pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:14.55pt"></td><td style="width:112.3pt"></td><td style="width:91.7pt"></td><td style="width:72pt"></td><td style="width:72pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:97.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of objector:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span>[</span><span style="font-style:italic">organisation or person intereste</span><span>d]</span></p></td><td colspan="3" style="width:235.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address for service</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the objector</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:235.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:97.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:235.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:90pt"></td><td style="width:96pt"></td><td style="width:72pt"></td><td style="width:78pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:151.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant:</span></p><p><span>[</span><span style="font-style:italic">employee or trade union whose rules entitle it to represent the industrial interests of employees to be covered by the order </span><span>(</span><span style="font-style:italic">or </span><span>the Sex Discrimination Commissioner)]</span></p></td><td colspan="3" style="width:180.75pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="3" style="width:151.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Address for service</span></p></td><td colspan="3" style="width:180.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:151.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><span style="font-style:italic"></span></p></td><td colspan="3" style="width:180.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="font-style:italic"></span></p></td><td colspan="2" style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="font-style:italic"></span></p></td><td colspan="4" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:72.45pt"></td><td style="width:29.55pt"></td><td style="width:72pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:360.15pt; border-collapse:collapse"><tbody><tr><td colspan="6" 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; text-align:justify; font-size:9pt"><span>In making this claim you </span><span style="font-weight:bold; font-style:italic">(the applicant) </span><span>should be aware that:</span></p><ul style="margin:0pt; padding-left:0pt"><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">an application must not be made on the ground that the termination was harsh, unjust or unreasonable where the employee was employed by an employer (including any related employer) who employed 100 or fewer employees (subsections 643</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif">(10) to (12) of the Act).</span></li><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">an application must not be made on the ground that the termination was harsh, unjust or unreasonable where the employee was terminated for genuine operational reasons or for reasons that include genuine operational reasons (subsections 643</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif">(8) to (9) of the Act).</span></li><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">specified categories of employees are excluded from making a claim under the Termination of Employment provisions of the Act (sections 638 and 639, subsections 643 (6) and (7) and section 674 of the Act).</span></li><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">an application must be lodged within 21 days after the day on which the termination took effect. In some circumstances the Commission can allow an extension of time (subsection 643 (14) or (15) of the Act).</span></li><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">The Commission may make an order for costs in certain circumstances (see section 658 of the Act).</span></li><li style="margin:3pt 0.3pt 3pt 26.69pt; padding-left:9.01pt; font-family:serif; font-size:9pt"><span style="font-family:'Times New Roman', serif">A fee is payable on lodgment of this application with the Commission unless a Registrar is satisfied that the applicant will suffer serious hardship if he or she pays the fee. The lodgment fee varies with the consumer price index. The current amount of the lodgment fee can be found on the Commission’s website. The lodgment fee is refundable under certain circumstances (subsection 644 (7) of the Act)</span></li></ul><p style="margin-top:3pt; margin-right:0.15pt; font-size:9pt"><span>Details in relation to these matters are available from the Industrial Registry or from the Commission’s website at www.airc.gov.au.</span></p></td></tr><tr><td colspan="6" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Details of Employee (the applicant)</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Mr</span><span style="font-family:Wingdings, serif"></span><span> Mrs </span><span style="font-family:Wingdings, serif"></span><span> Miss </span><span style="font-family:Wingdings, serif"></span><span> Ms</span><span style="font-family:Wingdings, serif"></span></p><p style="margin:3pt 0.15pt 3pt 15.95pt; text-indent:-15.95pt; font-size:9pt"><span>1</span><span style="width:11.45pt; text-indent:0pt; display:inline-block"> </span><span>Full name</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:4pt; font-size:9pt"><span>Family name:</span></p><p style="margin-top:4pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Given names:</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>2</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Address of applicant</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:12pt 13.6pt 12pt 3.7pt; font-size:9pt"><span></span></p><p style="margin-top:12pt; margin-left:3.7pt; margin-bottom:3pt; font-size:9pt"><span style="width:146.9pt; display:inline-block"></span><span>Postcode:</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>3</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Phone or fax number(s)</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Business hours ( )</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>After hours ( )</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Mobile:</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Fax ( )</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Email:</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>4</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Date of birth</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>day/month/year</span><span style="width:61.22pt; display:inline-block"> </span><span>/</span><span style="width:30pt; display:inline-block"> </span><span>/</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>5</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>First language</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>English </span><span style="font-family:Wingdings, serif"></span><span> other </span><span style="font-family:Wingdings, serif"></span><span> (</span><span style="font-style:italic">specify</span><span>)</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Is an interpreter needed? Yes </span><span style="font-family:Wingdings, serif"></span><span> No </span><span style="font-family:Wingdings, serif"></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Is there a family member or friend who can assist you? Yes </span><span style="font-family:Wingdings, serif"></span><span> No </span><span style="font-family:Wingdings, serif"></span></p></td></tr><tr><td colspan="6" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Details of Employer (the respondent)</span></p></td></tr><tr style="height:64.35pt"><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>6</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Name of employer’s business, company, corporation, authority or agency</span></p><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; page-break-after:avoid; font-size:9pt"><span style="width:15.9pt; text-indent:0pt; display:inline-block"></span><span>Contact person’s name</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>7</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Employer’s trading address or registered office</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="width:96.2pt; display:inline-block"></span><span>Postcode:</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span>Phone ( )</span><span style="width:63.21pt; display:inline-block"> </span><span>Fax ( ) Email:</span></p></td></tr><tr><td colspan="6" style="width:348.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#c0c0c0"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Details of employment</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>8</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Work performed for employer (occupation)</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span></span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>9</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Place of work</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span>Suburb/town:</span><span style="width:87.4pt; display:inline-block"> </span><span>Postcode:</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>10</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Date when you first worked for employer</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="width:114.2pt; display:inline-block"></span><span>/</span><span style="width:27.3pt; display:inline-block"> </span><span>/</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>11</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Date when you last worked for employer</span></p></td><td colspan="4" style="width:222.85pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="width:114.2pt; display:inline-block"></span><span>/</span><span style="width:27.3pt; display:inline-block"> </span><span>/</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; 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:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>12</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Date termination of employment took effect</span></p></td><td colspan="4" style="width:222.85pt; 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-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="width:114.2pt; display:inline-block"></span><span>/</span><span style="width:27.3pt; display:inline-block"> </span><span>/</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span style="font-style:italic">State the date when you think the termination of employment took effect if the date is different from the date when you last worked</span><span>.</span></p></td></tr><tr><td colspan="2" style="width:115.15pt; 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-right:0.3pt; margin-left:17.95pt; margin-bottom:3pt; text-indent:-17.95pt; font-size:9pt"><span style="width:17.95pt; text-indent:0pt; display:inline-block"></span><span>Did you receive written notice of termination/ separation certificate?</span></p></td><td colspan="4" style="width:222.85pt; 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-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> No </span><span style="font-family:Wingdings, serif"></span><span> Yes I attach a copy </span><span style="font-family:Wingdings, serif"></span></p></td></tr><tr><td colspan="6" style="width:348.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Extension of time</span></p></td></tr><tr><td colspan="6" style="width:348.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="BlockText" style="margin-top:1pt; margin-left:18.05pt; text-indent:-18pt; text-align:justify; font-size:9pt"><span>13</span><span style="width:9pt; text-indent:0pt; display:inline-block"> </span><span>This section must be completed if the application is lodged more than 21 days after the day on which the termination took effect (see item</span><span> </span><span>12). In such cases, the Commission may decide to dismiss the application without a hearing. [s647]</span></p><p style="margin:6pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; page-break-after:avoid; font-size:9pt"><span style="width:14.2pt; text-indent:0pt; display:inline-block"></span><span>My reason/s for seeking an extension of time to lodge this application is/are:</span><br><span>[</span><span style="font-style:italic">Write here or attach document</span><span>]</span></p><p style="margin:3pt 0.3pt 3pt 17.85pt; text-indent:-17.85pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin:3pt 0.3pt 3pt 17.85pt; text-indent:-17.85pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin:3pt 0.3pt 3pt 17.85pt; text-indent:-17.85pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin:3pt 0.3pt 3pt 17.85pt; text-indent:-17.85pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-left:17.85pt; text-indent:-17.85pt; page-break-after:avoid; font-size:9pt"><span></span></p></td></tr><tr><td colspan="6" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Details of your representative or union</span></p></td></tr><tr><td colspan="3" style="width:140.05pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; page-break-after:avoid; font-size:9pt"><span>14</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Is anyone representing you?</span></p></td><td colspan="3" style="width:197.95pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span>No </span><span style="font-family:Wingdings, serif"></span><span> go to item 18 / Yes </span><span style="font-family:Wingdings, serif"></span><span> go to item 15</span></p></td></tr><tr><td colspan="3" style="width:140.05pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>15</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Name of legal firm, union or other representative</span></p></td><td colspan="3" style="width:197.95pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span></span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p></td></tr><tr><td colspan="3" style="width:140.05pt; 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:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>16</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Name of contact person at legal firm, union or other representative</span></p></td><td colspan="3" style="width:197.95pt; 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-top:3pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span></span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p></td></tr><tr><td colspan="3" style="width:140.05pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>17</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Contact details of legal firm, union or other representative</span></p></td><td colspan="3" style="width:197.95pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span></span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span></span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span style="width:89.3pt; display:inline-block"></span><span>Postcode:</span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Phone ( )</span><span style="width:56.31pt; display:inline-block"> </span><span>Fax ( ) Email:</span></p></td></tr><tr><td colspan="6" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Grounds for application</span></p></td></tr><tr><td style="width:79.25pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:4pt; margin-left:15.9pt; margin-bottom:8pt; text-indent:-15.9pt; font-size:9pt"><span>18</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Grounds upon which this application is based</span></p><p style="margin:8pt 0.15pt 4pt 2.85pt; text-indent:2.85pt; font-size:9pt"><span></span></p></td><td colspan="5" style="width:258.75pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:4pt; margin-right:0.3pt; margin-bottom:8pt; font-size:9pt"><span>Identify the ground or grounds under subsection</span><span> </span><span>643 (1) of the Act upon</span><span style="font-style:italic"> </span><span>which this application is based:</span></p><p style="margin:8pt 0.3pt 8pt 39.95pt; text-indent:-39.95pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>(a)</span><span style="width:11.31pt; text-indent:0pt; display:inline-block"> </span><span>on the ground that the termination was harsh, unjust or unreasonable; and/or</span></p><p style="margin:8pt 0.15pt 8pt 39.9pt; text-indent:-39.9pt; font-size:9pt"><span style="width:18.6pt; text-indent:0pt; display:inline-block"></span><span>(b)</span><span style="width:10.81pt; text-indent:0pt; display:inline-block"> </span><span>on the ground of an alleged contravention of:</span></p><p style="margin:8pt 0.15pt 8pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>659</span><span style="width:30.06pt; text-indent:0pt; display:inline-block"> </span><span>(discrimination or other prohibited reasons); and/or</span></p><p style="margin:8pt 0.15pt 8pt 18.1pt; text-indent:0.5pt; font-size:9pt"><span>[</span><span style="font-style:italic">Write here the paragraph(s) in subsection .659</span><span style="font-style:italic"> </span><span style="font-style:italic">(2) of the Act on which the applicant relies</span><span>]</span></p><p style="margin:8pt 0.15pt 8pt 37.2pt; text-indent:-18.6pt; font-size:9pt"><span></span></p><p style="margin:8pt 0.15pt 8pt 37.2pt; text-indent:-18.6pt; font-size:9pt"><span></span></p><p style="margin:8pt 0.15pt 8pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>660</span><span style="width:30.06pt; text-indent:0pt; display:inline-block"> </span><span>(failure to notify Centrelink); and/or</span></p><p style="margin:8pt 0.15pt 4pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>661</span><span style="width:30.06pt; text-indent:0pt; display:inline-block"> </span><span>(failure to give notice of termination);</span></p></td></tr><tr><td style="width:79.25pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:4pt; margin-left:15.9pt; margin-bottom:4pt; text-indent:-15.9pt; font-size:9pt"><span>19</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>In respect of each ground identified, give a statement in summary form of the material facts on which the applicant relies.</span></p></td><td colspan="5" style="width:258.75pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; font-size:9pt"><span>[</span><span style="font-style:italic">Write here or attach document</span><span>]</span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p></td></tr><tr><td colspan="6" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Relief</span><span style="font-style:italic"> </span><span style="font-weight:bold">sought</span></p></td></tr><tr><td style="width:79.25pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:4pt; margin-left:15.9pt; margin-bottom:4pt; text-indent:-15.9pt; font-size:9pt"><span>20</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>What are you seeking?</span></p></td><td colspan="3" style="width:79.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; page-break-after:avoid; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> reinstatement</span></p></td><td style="width:79.4pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; margin-left:14.2pt; text-indent:-14.2pt; page-break-after:avoid; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span style="width:6.18pt; text-indent:0pt; display:inline-block"> </span><span>an amount in relation to the remuneration lost, or likely to have been lost, by you, because of the termination</span></p><p style="margin-right:0.15pt; margin-left:14.2pt; text-indent:-14.2pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin-right:0.15pt; margin-left:14.2pt; text-indent:-14.2pt; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin-right:0.3pt; margin-left:14.2pt; text-indent:-14.2pt; page-break-after:avoid; font-size:9pt"><span></span></p></td><td style="width:78.75pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-right:0.15pt; margin-left:8.8pt; text-indent:-8.8pt; page-break-after:avoid; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> </span><span>other </span><span>‑</span><span> </span><span style="font-style:italic">give details</span></p><p style="margin-right:0.15pt; page-break-after:avoid; font-size:9pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:89.95pt"></td><td style="width:35.9pt"></td><td style="width:24.9pt"></td><td style="width:29.1pt"></td><td style="width:90.1pt"></td><td style="width:89.45pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="2" style="width:348.7pt; 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:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Declaration</span></p></td></tr><tr><td colspan="2" style="width:348.7pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p style="margin-top:3pt; text-align:justify; font-size:10pt"><span style="height:0pt; margin-top:-3pt; text-align:left; display:block; position:relative; z-index:0"><img src="image.003.png" width="2" height="2" alt="" style="margin-top:-22.8pt; margin-left:122.65pt; position:absolute"></span><span>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 have failed for want of jurisdiction) by me or on my behalf under any other provision of the </span><span style="font-style:italic">Workplace Relations Act 1996</span><span> or under any other law of the Commonwealth or of a State or Territory.</span></p><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:10pt"><span style="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 rowspan="2" style="width:122.25pt; 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-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic">The employee must sign this declaration unless the application was prepared by a legal firm, union or other representative of the employee.</span></p></td><td style="width:215.75pt; 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-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of employee</span><span>]</span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin-right:1.7pt; margin-left:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr><tr><td style="width:215.75pt; 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:9pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:9pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:6pt; margin-left:0pt; font-size:9pt"><span>[S</span><span style="font-style:italic">ignature of legal firm, union 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:9pt"><span></span></p><p style="margin-right:1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="font-weight:bold">Details of union making application</span></p></td></tr><tr><td colspan="5" style="width:127.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.15pt; margin-left:15.95pt; margin-bottom:3pt; text-indent:-15.95pt; font-size:9pt"><span>1</span><span style="width:11.45pt; text-indent:0pt; display:inline-block"> </span><span>Full name of union</span></p></td><td colspan="5" style="width:205.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><br><span></span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="5" style="width:127.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>2</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Address of union</span></p></td><td colspan="5" style="width:205.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:12pt 13.6pt 12pt 3.7pt; font-size:9pt"><span></span></p><p style="margin-top:12pt; margin-left:3.7pt; margin-bottom:3pt; font-size:9pt"><span style="width:125.95pt; display:inline-block"></span><span>Postcode:</span></p></td></tr><tr><td colspan="5" style="width:127.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>3</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Phone or fax number(s)</span></p></td><td colspan="5" style="width:205.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Business hours: </span><span></span><span>(</span><span> </span><span></span><span>)</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>After hours: </span><span></span><span>(</span><span> </span><span></span><span>)</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Mobile:</span><span> </span><span>(</span><span> </span><span></span><span>)</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Fax:</span><span> </span><span>(</span><span> </span><span></span><span>)</span></p><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span>Email:</span></p></td></tr><tr style="height:31.15pt"><td colspan="5" style="width:127.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>4</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Union contact person for notices from the Commission</span></p></td><td colspan="5" style="width:205.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">The application is made on behalf of the following employee/s</span></p></td></tr><tr style="height:47.25pt"><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>5</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span style="font-style:italic">[Write here name/s of employee/s or attach list]</span></p></td></tr><tr style="height:52.85pt"><td colspan="3" style="width:109.9pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>6</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Date/s of termination of employee/s employment</span></p></td><td colspan="7" style="width:222.85pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic">[write here or attach list]</span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span style="font-weight:bold">Details of employer (the respondent)</span></p></td></tr><tr style="height:3pt"><td colspan="3" style="width:109.9pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>7</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Name of employer’s business, company, corporation, authority or agency</span></p><p style="margin:3pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span style="width:15.9pt; text-indent:0pt; display:inline-block"></span><span>Contact person’s name</span></p></td><td colspan="7" style="width:222.85pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.3pt; margin-bottom:3pt; font-size:9pt"><span></span></p></td></tr><tr><td colspan="3" style="width:109.9pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span>8</span><span style="width:11.4pt; text-indent:0pt; display:inline-block"> </span><span>Employer’s trading address or registered office</span></p></td><td colspan="7" style="width:222.85pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><br><span style="width:145.65pt; display:inline-block"></span><span>Postcode:</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span>Phone: </span><span></span><span>(</span><span> </span><span></span><span>)</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span>Fax: </span><span></span><span>(</span><span> </span><span>)</span></p><p style="margin-top:3pt; margin-right:0.15pt; margin-bottom:3pt; font-size:9pt"><span>Email:</span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Extension of time</span></p></td></tr><tr style="height:34.4pt"><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin:1pt 0.8pt 6pt 18.05pt; text-indent:-18pt; text-align:justify; font-size:9pt"><span>9</span><span style="width:13.5pt; text-indent:0pt; display:inline-block"> </span><span>This section must be completed if the application is lodged more than 21 days after the day on which the termination took effect (see item 6). In such cases, the Commission may decide to dismiss the application without a hearing (section 647 of the Act).</span></p><p style="margin:6pt 0.3pt 3pt 15.9pt; text-indent:-15.9pt; font-size:9pt"><span style="width:15.9pt; text-indent:0pt; display:inline-block"></span><span>My reason/s for seeking an extension of time to lodge this application is/are:</span><br><span>[</span><span style="font-style:italic">write here or attach document</span><span>]</span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Grounds for application</span></p></td></tr><tr><td colspan="2" style="width:85.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:4pt; margin-left:15.9pt; margin-bottom:4pt; text-indent:-15.9pt; font-size:9pt"><span>10</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>Grounds upon which this application is based</span></p></td><td colspan="8" style="width:247.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:4pt; margin-right:0.3pt; margin-bottom:8pt; font-size:9pt"><span>Identify the ground or grounds under subsection</span><span> </span><span>643 (1) of the Act upon</span><span style="font-style:italic"> </span><span>which this application is based</span></p><p style="margin-top:8pt; margin-right:0.3pt; margin-bottom:8pt; font-size:9pt"><span>On the ground of alleged contravention of:</span></p><p style="margin:8pt 0.15pt 4pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>659 (discrimination or other prohibited reasons); and/or</span></p><p style="margin:4pt 0.3pt 8pt 18.15pt; text-indent:0.55pt; font-size:9pt"><span>[</span><span style="font-style:italic">write here the paragraph(s) in subsection 659</span><span style="font-style:italic"> </span><span style="font-style:italic">(2) of the Act on which the applicant relies</span><span>]</span></p><p style="margin:8pt 0.15pt 8pt 37.2pt; text-indent:-18.6pt; font-size:9pt"><span></span></p><p style="margin:8pt 0.15pt 8pt 37.2pt; text-indent:-18.6pt; font-size:9pt"><span></span></p><p style="margin:8pt 0.15pt 8pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>660 (failure to notify Centrelink); and/or</span></p><p style="margin:8pt 0.15pt 4pt 18.6pt; text-indent:-18.6pt; font-size:9pt"><span style="font-family:Wingdings, serif; font-weight:bold"></span><span style="width:10.58pt; text-indent:0pt; font-weight:bold; display:inline-block"> </span><span>section</span><span> </span><span>661 (failure to give notice of termination).</span></p></td></tr><tr><td colspan="2" style="width:85.3pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:4pt; margin-left:15.9pt; margin-bottom:4pt; text-indent:-15.9pt; font-size:9pt"><span>11</span><span style="width:6.9pt; text-indent:0pt; display:inline-block"> </span><span>In respect of each ground identified, give a statement in summary form of the material facts on which the applicant relies</span></p></td><td colspan="8" style="width:247.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.15pt; font-size:9pt"><span>[</span><span style="font-style:italic">Write here or attach document</span><span>]</span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:0.15pt; font-size:9pt"><span style="font-style:italic"></span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Relief</span><span style="font-style:italic"> </span><span style="font-weight:bold">sought</span></p></td></tr><tr style="height:53.55pt"><td style="width:71pt; border:1pt solid #000000; vertical-align:top"><p style="margin-top:4pt; margin-left:21.5pt; margin-bottom:4pt; text-indent:-16.1pt; font-size:9pt"><span>12</span><span style="width:7.1pt; text-indent:0pt; display:inline-block"> </span><span>What are you seeking?</span></p></td><td colspan="5" style="width:72.35pt; border:1pt solid #000000; vertical-align:top"><p style="margin-right:0.15pt; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> </span><span></span><span>reinstatement</span></p></td><td colspan="3" style="width:105.05pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.15pt; margin-left:14.2pt; text-indent:-14.2pt; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> </span><span></span><span>an amount in relation to the remuneration lost, or likely to have been lost, by you, because of the termination</span></p></td><td style="width:82.35pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:0.15pt; margin-left:8.8pt; text-indent:-8.8pt; font-size:9pt"><span style="font-family:Wingdings, serif"></span><span> </span><span>other </span><span></span><span>‑</span><span> </span><span style="font-style:italic">give details</span></p></td></tr><tr><td style="width:71.5pt; border-top:1pt solid #000000; border-left:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td><td colspan="2" style="width:48.6pt; border-top:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td><td colspan="3" style="width:24.75pt; border-top:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td><td style="width:16.65pt; border-top:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td><td style="width:96pt; border-top:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td><td colspan="2" style="width:95.65pt; border-top:1pt solid #000000; border-right:1pt solid #000000; vertical-align:middle"><p style="font-size:0.5pt"><span></span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border-right:1pt solid #000000; border-left:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:1pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Declaration</span></p></td></tr><tr><td colspan="10" style="width:343.45pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:3pt; margin-right:0.3pt; margin-bottom:3pt; page-break-after:avoid; font-size:10pt"><span style="font-weight:bold">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 style="height:106pt"><td colspan="4" style="width:116.85pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-top:1pt; margin-right:1.7pt; font-size:9pt"><span style="font-style:italic">Union representative must sign here</span></p></td><td colspan="6" style="width:215.9pt; border:1pt solid #000000; padding-right:4.85pt; padding-left:4.85pt; vertical-align:top"><p style="margin-right:1.7pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-right:1.75pt; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of union representative</span><span>]</span></p><p style="margin-right:1.75pt; font-size:9pt"><span></span></p><p style="margin-right:1.75pt; font-size:9pt"><span style="font-style:italic">Name [print]</span></p><p style="margin-right:1.75pt; font-size:9pt"><span></span></p><p style="margin-right:1.7pt; margin-left:1.75pt; font-size:9pt"><span>Date</span><span> </span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span>/</span><span> </span><span></span><span></span><span></span><span></span><span></span><span></span><span>/</span></p><p style="margin-right:1.75pt; font-size:9pt"><span></span></p><p style="margin-right:1.75pt; font-size:9pt"><span style="font-style:italic">Position</span><span style="font-style:italic"></span></p></td></tr><tr style="height:0pt"><td style="width:72pt"></td><td style="width:24pt"></td><td style="width:24.6pt"></td><td style="width:6.95pt"></td><td style="width:10.45pt"></td><td style="width:7.35pt"></td><td style="width:16.65pt"></td><td style="width:96pt"></td><td style="width:3.1pt"></td><td style="width:93.05pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:347.65pt; margin-left:6.85pt; border-collapse:collapse"><tbody><tr><td colspan="4" 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-top:3pt; 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">Please place a tick or cross, where necessary, in the boxes below.</span></p></td></tr><tr><td colspan="4" 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:3pt; 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">Application details </span><span style="font-family:Arial, sans-serif; font-size:10pt; font-weight:bold; font-style:italic">(as stated in Form R27 or R27A)</span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">1</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">Former employee’s full name as appearing on employee’s application</span></p></td><td colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:14.55pt; margin-bottom:3pt; text-indent:-12.8pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">2</span><span style="width:7.24pt; 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">Commission Case/File Number</span></p></td><td colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">U</span></p></td></tr><tr><td colspan="4" 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:3pt; 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">Details of Employer</span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.75pt; margin-bottom:6pt; 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 class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:90.65pt; 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:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">[</span><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Family name</span><span style="font-family:Arial, sans-serif; font-size:10pt">] [</span><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Given nam</span><span style="font-family:Arial, sans-serif; font-size:10pt">es]</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:6pt; 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:6pt; margin-left:1.75pt; margin-bottom:6pt; 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:6pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Mobile:</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Email:</span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 status</span></p></td><td colspan="3" style="width:163.3pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; 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:6pt; margin-left:1.7pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">ACN _______________</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; 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"> Partnership</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; 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"> Sole trader</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; 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"> Government Authority</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:3pt; 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"> Other (specify)</span></p></td></tr><tr><td style="width:162.2pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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 colspan="3" style="width:163.3pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:74.75pt; margin-bottom:6pt; text-indent:-72pt; text-align:left"><span style="font-family:Wingdings, serif; font-size:10pt"></span><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></p><p class="Schedulepara" style="margin-top:6pt; margin-left:2.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">If no, what was the name and address of employer at time of termination?</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:2.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td colspan="4" 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:3pt; 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">Details of employer’s representative</span></p></td></tr><tr><td colspan="3" style="width:221.6pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; 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">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">Is anyone representing the employer?</span></p></td><td style="width:103.9pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; 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"> go to item 10</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><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 13</span></p></td></tr><tr><td colspan="3" style="width:221.6pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><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">Name of legal firm, employer organisation or other representative</span></p></td><td style="width:103.9pt; 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:3pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td colspan="3" style="width:221.6pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><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 contact person at legal firm, employer organisation or other representative</span></p></td><td style="width:103.9pt; 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:3pt; margin-left:0pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td colspan="3" style="width:221.6pt; border:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top"><p class="Schedulepara" style="margin-top:3pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">12</span><span style="width:5.03pt; 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 legal firm, employer organisation or other representative</span></p></td><td style="width:103.9pt; 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:3pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p style="margin-top:6pt; margin-right:0.3pt; margin-bottom:6pt; font-size:9pt"><span style="width:112.45pt; display:inline-block"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:37.25pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Postcode</span><span style="font-size:10pt">:</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">Phone ( )</span><span style="width:203.17pt; font-family:Arial, sans-serif; font-size:10pt; display:inline-block"> </span><span style="font-family:Arial, sans-serif; font-size:10pt">Fax ( ) Email:</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:136.4pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td colspan="4" 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:3pt; 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">Reasons for termination</span></p></td></tr><tr><td colspan="2" 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:3pt; margin-left:17.85pt; margin-bottom:6pt; text-indent:-16.1pt; text-align:left"><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">In summary form specify the facts on which the respondent relies and admit or dispute, either with or without qualification, each part of the claim made by the applicant.</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:17.85pt; margin-bottom:6pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:17.85pt; margin-bottom:6pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.1pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td><td colspan="2" 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:3pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt">[</span><span style="font-family:Arial, sans-serif; font-size:10pt; font-style:italic">Write here or attach document</span><span style="font-family:Arial, sans-serif; font-size:10pt">]</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:6pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.75pt; margin-bottom:3pt; text-indent:0pt; text-align:left"><span style="font-family:Arial, sans-serif; font-size:10pt"></span></p></td></tr><tr><td colspan="4" 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-top:3pt; margin-left:17.85pt; margin-bottom:3pt; text-indent:-16.15pt; text-align:left; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Late lodgment objection (if applicable)</span></p></td></tr><tr><td colspan="4" 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:3pt; margin-left:17.85pt; margin-bottom:6pt; 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">If the application was lodged in the Commission more than 21 days after the day on which the termination took effect, the applicant must seek an extension of time for lodgment. The Commission may decide to dismiss the application without a hearing [section 647 of the Act] .</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; text-indent:0pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif">Please indicate whether the employer objects to the Commission extending the time for lodgment.</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:19.7pt; margin-bottom:6pt; text-indent:-18pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif"><span style="font-family:Wingdings, serif"></span></span><span style="width:9.09pt; font:7pt 'Times New Roman'; 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><p class="Schedulepara" style="margin-top:6pt; margin-left:19.7pt; margin-bottom:6pt; text-indent:-18pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif"><span style="font-family:Wingdings, serif"></span></span><span style="width:9.09pt; font:7pt 'Times New Roman'; display:inline-block"> </span><span style="font-family:Arial, sans-serif">I object to the Commission extending the time for lodgment but do </span><span style="font-family:Arial, sans-serif; text-decoration:underline">not</span><span style="font-family:Arial, sans-serif"> object to conciliation before determination of the application to extend time; OR</span></p><p class="Schedulepara" style="margin-top:6pt; margin-left:19.7pt; margin-bottom:3pt; text-indent:-18pt; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif"><span style="font-family:Wingdings, serif"></span></span><span style="width:9.09pt; font:7pt 'Times New Roman'; 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><tr><td colspan="4" 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:3pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left; page-break-after:avoid; line-height:normal; font-size:10pt"><span style="font-family:Arial, sans-serif; font-weight:bold">Dismissal for want of jurisdiction or application is frivolous, vexatious or lacking in substance (if applicable)</span></p></td></tr><tr><td colspan="4" 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 style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid"><span style="font-style:italic">Note</span><span> </span><span></span><span></span><span>If the employer intends to move for the dismissal of the application for want of jurisdiction, Form</span><span style="font-style:italic"> </span><span>R29 must be completed and filed.</span></p></td></tr><tr><td colspan="4" 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 style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid"><span></span><span>If the employer intends to move for the dismissal of the application on the ground that the application is frivolous, vexatious or lacking in substance, Form R30 must be completed and filed.</span></p></td></tr><tr style="height:0pt"><td style="width:172.9pt"></td><td style="width:24pt"></td><td style="width:35.4pt"></td><td style="width:114.6pt"></td></tr></tbody></table>
```
<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 class="Schedulepara" style="margin-top:3pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left; page-break-after:avoid; line-height:normal; 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 class="Schedulepara" style="margin-top:3pt; margin-left:1.7pt; margin-bottom:3pt; text-indent:0pt; text-align:left; page-break-after:avoid; line-height:normal; 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; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span style="font-style:italic">The employer must sign this declaration unless the application was prepared by a legal firm, 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-top:3pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin-top:6pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin-top:6pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>[</span><span style="font-style:italic">Signature of employer</span><span>]</span></p><p style="margin-top:6pt; margin-right:1.75pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin:6pt 1.7pt 3pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</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-top:3pt; margin-left:0pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:10pt"><span style="font-family:Arial, sans-serif">[</span><span style="font-family:Arial, sans-serif; font-style:italic">Signature of legal firm, employer organisation or other representative</span><span style="font-family:Arial, sans-serif">]</span></p><p style="margin-top:9pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span></span></p><p style="margin-top:6pt; margin-right:1.75pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:360.1pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:348.65pt; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:3pt; margin-right:14.2pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Declaration</span></p></td></tr><tr><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:3pt; font-size:9pt"><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></td></tr><tr><td rowspan="2" style="width:110.35pt; 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; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic">The employer must sign this notice unless a legal firm, employer organisation or other representative has prepared the notice.</span></p></td><td style="width:227.6pt; 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:9pt"><span style="font-style:italic"></span></p><p style="margin-right:1.7pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin:3pt 1.7pt 6pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of employer</span><span>]</span></p><p style="margin:6pt 1.7pt 6pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin:6pt 1.7pt 3pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr><tr><td style="width:227.6pt; 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-top:3pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span style="font-family:Arial, sans-serif"></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of legal firm, employer organisation or other representative</span><span>]</span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span style="font-family:Arial, sans-serif"></span></p><p style="margin-top:9pt; margin-right:1.75pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:360.1pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:348.65pt; border-bottom:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#ffffff"><p style="font-size:9pt"><span style="font-weight:bold">Commission Case/File Number: U</span></p></td></tr><tr><td colspan="2" style="width:348.65pt; border-top:0.75pt solid #000000; padding-right:4.97pt; padding-left:4.97pt; vertical-align:top; background-color:#f2f2f2"><p style="margin:3pt 14.2pt 3pt 1.7pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">The employer moves for the dismissal of the employee’s application, to the extent that it is made on the ground in paragraph 643 (1) (a) of the Act (i.e. harsh, unjust or unreasonable), on the ground that it is frivolous, vexatious or lacking in substance</span></p></td></tr><tr><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:3pt; text-align:justify; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Summary of facts in support:</span></p></td></tr><tr style="height:51.8pt"><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span>[</span><span style="font-style:italic">Write here and/or attach document(s)</span><span>]</span></p><p style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span style="font-weight:bold"></span></p><p style="margin-top:6pt; margin-bottom:3pt; text-align:justify; font-size:9pt"><span style="font-weight:bold; font-style:italic"></span></p></td></tr><tr style="height:16.6pt"><td colspan="2" style="width:348.65pt; 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:3pt; margin-bottom:3pt; text-align:justify; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Particular cost that would be caused to the business of the employer in attending a hearing</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span>Specify the cost to the business of the employer in attending a hearing on this motion to dismiss the employee’s application on the above ground:</span></p><p style="margin-top:6pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span>[</span><span style="font-style:italic">Write here and/or attach document(s)</span><span>]</span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-top:6pt; margin-bottom:3pt; text-align:justify; font-size:9pt"><span style="font-weight:bold"></span></p></td></tr><tr style="height:16pt"><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:3pt; text-align:justify; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Objection to conciliation occurring before this motion is dealt with</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:6pt; text-align:justify; font-size:9pt"><span>Does the employer object to conciliation before this motion is dealt with by the Commission?</span></p><p style="margin-top:6pt; margin-left:1.7pt; margin-bottom:3pt; text-align:justify"><span style="font-family:Wingdings, serif"></span><span style="font-size:9pt"> Yes </span><span style="font-family:Wingdings, serif"></span><span style="font-size:9pt"> No</span></p></td></tr><tr><td colspan="2" style="width:348.65pt; 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:3pt; margin-right:14.2pt; margin-bottom:3pt; page-break-after:avoid; font-size:9pt"><span style="font-weight:bold">Declaration</span></p></td></tr><tr><td colspan="2" style="width:348.65pt; 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:3pt; margin-left:1.7pt; margin-bottom:3pt; font-size:9pt"><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></td></tr><tr><td rowspan="2" style="width:111.65pt; 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; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic">The employer must sign this notice unless a legal firm, employer organisation or other representative has prepared the notice.</span></p></td><td style="width:226.3pt; 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-top:3pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin-top:6pt; margin-right:1.7pt; margin-bottom:6pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span style="font-style:italic"></span></p><p style="margin:6pt 1.7pt 6pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of employer</span><span>]</span></p><p style="margin:6pt 1.7pt 6pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span></span></p><p style="margin:6pt 1.7pt 3pt 1.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span>Date</span><span> </span><span>/</span><span> </span><span>/</span></p></td></tr><tr><td style="width:226.3pt; 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-top:3pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span></span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span>[</span><span style="font-style:italic">Signature of legal firm, employer organisation or other representative</span><span>]</span></p><p class="BlockText" style="margin-top:9pt; margin-left:0pt; margin-bottom:9pt; font-size:9pt"><span></span></p><p style="margin-top:9pt; margin-right:1.75pt; margin-bottom:3pt; page-break-inside:avoid; page-break-after:avoid; font-size:9pt"><span></span><span>Date </span><span></span><span>/ </span><span></span><span>/</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:134.55pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant</span></p></td><td colspan="3" style="width:206.4pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:3.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:337.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="4" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:14.55pt"></td><td style="width:84pt"></td><td style="width:46.8pt"></td><td style="width:37.2pt"></td><td style="width:72pt"></td><td style="width:108pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:134.55pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span>Name of party</span></p></td><td colspan="3" style="width:206.4pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:3.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:337.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the other party</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="4" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:14.55pt"></td><td style="width:84pt"></td><td style="width:46.8pt"></td><td style="width:37.2pt"></td><td style="width:72pt"></td><td style="width:108pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of notifier:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:13.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:319.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the notifier</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:24pt"></td><td style="width:66pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:104.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:227.75pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:104.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Street Address</span></p></td><td colspan="3" style="width:227.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:2pt; margin-bottom:4pt"><span></span></p><p style="margin-top:4pt; margin-bottom:2pt"><span></span></p></td></tr><tr><td style="width:104.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:227.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:104.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td style="width:65.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr><td style="width:104.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:65.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:104.65pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:227.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:115.45pt"></td><td style="width:76.55pt"></td><td style="width:72pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of notifier:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span>[</span><span style="font-style:italic">organisation, employer or Minister</span><span>]</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the notifier</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:78pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of party(s):</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the party(s)</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:78pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of workplace inspector:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of applicant:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span>[</span><span style="font-style:italic">permit holder, organisation</span><span>]</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:72pt"></td><td style="width:108pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of organisation:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:78pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of workplace inspector:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:84pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of applicant:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span>[</span><span style="font-style:italic">permit holder/ official of the organisation</span><span>]</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Official position held</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Organisation</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:72pt"></td><td style="width:108pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of employer:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the employer</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:143.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name of applicant:</span></p><p style="margin-top:6pt; margin-bottom:6pt; font-size:14pt"><span style="font-family:Wingdings, serif"></span><span> </span><span style="font-size:12pt">permit holder;</span></p><p style="margin-top:6pt; margin-bottom:6pt; font-size:14pt"><span style="font-family:Wingdings, serif"></span><span> </span><span style="font-size:12pt">permit holder’s organisation;</span></p><p style="margin-top:6pt; margin-bottom:6pt; font-size:14pt"><span style="font-family:Wingdings, serif"></span><span> </span><span style="font-size:12pt">an affected employer;</span></p><p style="margin-top:6pt; margin-bottom:3pt; font-size:14pt"><span style="font-family:Wingdings, serif"></span><span> </span><span style="font-size:12pt">an occupier of, or an employer who employs employees who carry out work on, OHS premises</span></p></td><td colspan="3" style="width:189.3pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:143.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:189.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="3" style="width:143.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:189.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:85.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Email address:</span></p></td><td colspan="4" style="width:247.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:78pt"></td><td style="width:57.9pt"></td><td style="width:38.1pt"></td><td style="width:72pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of party(s):</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the party(s)</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="2" style="width:163.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:102pt"></td><td style="width:72pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:108pt"></td><td style="width:72pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:108pt"></td><td style="width:72pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:29pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td></tr><tr><td style="width:169.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:163.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:84pt"></td><td style="width:78pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name:</span></p><p style="margin-top:6pt; margin-bottom:3pt; font-size:9pt"><span style="font-style:italic">[person bound by the pre</span><span style="font-style:italic">‑</span><span style="font-style:italic">reform certified agreement]</span></p></td></tr><tr style="height:39.7pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:9.3pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td></tr><tr><td style="width:169.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:163.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Name:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span style="font-style:italic">[person bound by the pre</span><span style="font-style:italic">‑</span><span style="font-style:italic">reform certified agreement]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:4pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td></tr><tr><td style="width:163.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:169.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:78pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span><br><span style="font-style:italic">[party to the old IR agreement]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:4pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span><span style="width:195pt; display:inline-block"></span></p></td></tr><tr><td style="width:169.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:163.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:96pt"></td><td style="width:72pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name of applicant:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:96pt"></td><td style="width:72pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span>Name of applicant:</span></p></td></tr><tr style="height:35.55pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Address:</span><br><span></span></p></td></tr><tr style="height:9.4pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td></tr><tr><td style="width:145.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="width:178.34pt; display:inline-block"></span></p></td><td style="width:187.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="width:175.02pt; display:inline-block"></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:343.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="page-break-after:avoid"><span>Name of applicant:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address:</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:4pt"><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span><br><span style="font-size:9pt">[</span><span style="font-size:9pt; font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span style="font-size:9pt">]</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td></tr><tr><td style="width:145.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span><span style="width:178.34pt; display:inline-block"></span></p></td><td style="width:187.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td></tr><tr><td colspan="2" style="width:343.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span><span style="width:175.02pt; display:inline-block"></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:93.75pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant</span></p></td><td colspan="3" style="width:247.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:93.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:93.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:9.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:93.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:247.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:93.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:91.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:93.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:247.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:20.55pt"></td><td style="width:84pt"></td><td style="width:84pt"></td><td style="width:72pt"></td><td style="width:102pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:116.15pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant</span></p></td><td colspan="3" style="width:224.8pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:9.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="4" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:20.55pt"></td><td style="width:78pt"></td><td style="width:28.4pt"></td><td style="width:61.6pt"></td><td style="width:78pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="2" style="width:70.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>IN the matter of:</span></p></td><td style="width:267.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td style="width:47.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span style="font-weight:bold"></span></p></td><td colspan="2" style="width:290.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:center"><span>[</span><span style="font-style:italic">Title of *collective agreement/ *pre</span><span style="font-style:italic">‑</span><span style="font-style:italic">reform certified agreement/*State transitional instrument</span><span>]</span></p></td></tr><tr style="height:0pt"><td style="width:58.4pt"></td><td style="width:22.7pt"></td><td style="width:278.3pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:362.55pt; border-collapse:collapse"><tbody><tr><td colspan="3" style="width:116.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of applicant:</span></p><p><span>[</span><span style="font-style:italic">outgoing employer, incoming employer, transferring employee or organisation</span><span>]</span></p></td><td colspan="3" style="width:224.6pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid"><span>Contact Person:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:9.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:331.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="4" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td colspan="2" style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:61.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:97.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:87.75pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="4" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:20.55pt"></td><td style="width:78pt"></td><td style="width:28.6pt"></td><td style="width:55.4pt"></td><td style="width:72pt"></td><td style="width:108pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:78pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:79.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name:</span></p></td><td colspan="3" style="width:253.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the applicant</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:253.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:85.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:79.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:253.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:72pt"></td><td style="width:90pt"></td><td style="width:78pt"></td><td style="width:96pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:108.9pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of objector:</span><br><span>[</span><span style="font-style:italic">organisation, association or person interested in lodging the notice of objection</span><span>]</span></p></td><td colspan="3" style="width:223.5pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the objector</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:55.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:79.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:223.5pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:101.7pt"></td><td style="width:66.3pt"></td><td style="width:78pt"></td><td style="width:90pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:108.9pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of objector:</span></p><p><span></span></p><p><span>[</span><span style="font-style:italic">person interested in lodging the notice of objection</span><span>]</span></p></td><td colspan="3" style="width:223.5pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the objector</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:223.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:61.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:108.9pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:223.5pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:101.7pt"></td><td style="width:72.3pt"></td><td style="width:78pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:354pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:100.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Name of objector:</span><br><span>[</span><span style="font-style:italic">person interested in lodging the notice of objection</span><span>]</span></p></td><td colspan="3" style="width:232.05pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span></span></p></td></tr><tr><td colspan="2" style="width:100.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:6pt"><span>Address</span></p><p style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:232.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:100.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Contact Person:</span></p></td><td colspan="3" style="width:232.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:7.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td colspan="4" style="width:325.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; font-size:9pt"><span>[</span><span style="font-style:italic">also include the name of any firm of solicitors or agent acting for the objector</span><span>]</span></p></td></tr><tr><td colspan="2" style="width:100.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Phone No:</span></p></td><td colspan="3" style="width:232.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:100.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Facsimile No:</span></p></td><td style="width:70.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td><td style="width:67.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Mobile No:</span></p></td><td style="width:73.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td colspan="2" style="width:100.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span>Email address:</span></p></td><td colspan="3" style="width:232.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:18pt"></td><td style="width:93.15pt"></td><td style="width:80.85pt"></td><td style="width:78pt"></td><td style="width:84pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:70.9pt"><td rowspan="3" style="width:293.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:6pt; text-align:justify; page-break-inside:avoid; widows:0; orphans:0"><span>DO YOU APPROVE THE PROPOSED AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>)</span><span style="font-style:italic"> </span><span>WITH THE FOLLOWING ORGANISATION(S), NAMELY, (</span><span style="font-style:italic">name of organisation or each organisation with which amalgamation is proposed</span><span>), IN ACCORDANCE WITH THE SCHEME FOR AMALGAMATION A COPY OF THE OUTLINE OF WHICH HAS BEEN SENT TO YOU WITH THIS BALLOT PAPER?</span></p></td><td style="width:23.65pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p></td><td style="width:15.45pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:14.2pt"><td style="width:23.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span>YES</span></p></td><td style="width:15.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:14.2pt"><td style="width:23.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span>NO</span></p></td><td style="width:15.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:51pt"><td rowspan="2" style="width:300.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:6pt; text-align:justify; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span>DO YOU APPROVE THE PROPOSED AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>)</span><span style="font-style:italic"> </span><span>WITH THE FOLLOWING ORGANISATION(S), NAMELY, (</span><span style="font-style:italic">name of organisation or each organisation with which amalgamation is proposed</span><span>), IN ACCORDANCE WITH THE SCHEME FOR AMALGAMATION A COPY OF THE OUTLINE OF WHICH HAS BEEN SENT TO YOU WITH THIS BALLOT PAPER?</span></p></td><td style="width:43.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:43.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="text-align:right; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td rowspan="3" style="width:295.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-left:5.95pt; text-align:justify; widows:0; orphans:0"><span>DO YOU APPROVE THE PROPOSED AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>)</span><span style="font-style:italic"> </span><span>WITH THE FOLLOWING ORGANISATIONS NAMELY, (</span><span style="font-style:italic">name of each organisation with which amalgamation is proposed</span><span>),</span><span style="font-style:italic"> </span><span>IN ACCORDANCE WITH THE SCHEME FOR AMALGAMATION A COPY OF THE OUTLINE OF WHICH HAS BEEN SENT TO YOU WITH THIS BALLOT PAPER?</span></p></td><td colspan="2" style="width:64.1pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; widows:0; orphans:0"><span></span></p><p style="text-align:right; widows:0; orphans:0"><span></span></p><p style="text-align:right; widows:0; orphans:0"><span></span></p><p style="text-align:right; widows:0; orphans:0"><span></span></p><p style="text-align:right; widows:0; orphans:0"><span></span></p><p style="text-align:right; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:35.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; widows:0; orphans:0"><span>YES</span></p></td><td style="width:17.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:35.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; widows:0; orphans:0"><span>NO</span></p></td><td style="width:17.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td rowspan="3" style="width:295.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-left:6pt; text-align:justify; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span>IF THE PROPOSED AMALGAMATION IN RELATION TO WHICH YOU HAVE JUST RECORDED YOUR VOTE DOES NOT TAKE PLACE, DO YOU APPROVE THE AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>)</span><span style="font-style:italic"> </span><span>WITH THE OTHER ORGANISATIONS CONCERNED IN THE AMALGAMATION WHOSE MEMBERS GIVE A SIMILAR APPROVAL?</span></p></td><td colspan="2" style="width:64.1pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:35.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; widows:0; orphans:0"><span>YES</span></p></td><td style="width:17.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:35.8pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; widows:0; orphans:0"><span>NO</span></p></td><td style="width:17.5pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:2pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:51pt"><td rowspan="2" style="width:300.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-left:6pt; text-align:justify; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span>DO YOU APPROVE THE PROPOSED AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>)</span><span style="font-style:italic"> </span><span>WITH THE FOLLOWING ORGANISATION(S), NAMELY, (</span><span style="font-style:italic">name of organisation with which amalgamation is proposed</span><span>), IN ACCORDANCE WITH THE SCHEME FOR AMALGAMATION A COPY OF THE OUTLINE OF WHICH HAS BEEN SENT TO YOU WITH THIS BALLOT PAPER?</span></p></td><td style="width:43.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; text-align:right; page-break-inside:avoid; page-break-after:avoid; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:43.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:73.5pt"><td rowspan="2" style="width:303.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-left:9.15pt; text-align:justify; widows:0; orphans:0"><span>IF THE PROPOSED AMALGAMATION IN RELATION TO WHICH YOU HAVE JUST RECORDED YOUR VOTE DOES NOT TAKE PLACE, DO YOU APPROVE THE AMALGAMATION OF (</span><span style="font-style:italic">name of organisation whose members are voting</span><span>) WITH THE OTHER ORGANISATIONS CONCERNED IN THE AMALGAMATION WHOSE MEMBERS GIVE A SIMILAR APPROVAL?</span></p></td><td style="width:43.35pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:right; widows:0; orphans:0"><span></span></p><p style="margin-top:6pt; text-align:right; widows:0; orphans:0"><span></span></p></td></tr><tr style="height:28.35pt"><td style="width:43.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="text-align:right; widows:0; orphans:0"><span></span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:370.95pt; margin-right:auto; margin-left:auto; border-collapse:collapse"><thead><tr><td colspan="2" style="width:360.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmendHead" style="margin-right:0pt"><span>ad. = added or inserted</span><span> </span><span>am. = amended</span><span> </span><span>rep. = repealed</span><span> </span><span>rs. = repealed and substituted</span></p></td></tr><tr><td style="width:113.05pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Provision affected</span></p></td><td style="width:236.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>How affected</span></p></td></tr></thead><tbody><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 1</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 3</span><span style="width:96.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.................</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 8</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 30</span><span style="width:91.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">................</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 11A</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>Part 11A</span><span style="width:78.38pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 54A</span><span style="width:85.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 12</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>Heading to Part 12</span><span style="width:38.35pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.......</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>rs. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 55</span><span style="width:91.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">................</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>rs. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 55A</span><span style="width:85.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 59A</span><span style="width:85.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 13</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 61A</span><span style="width:85.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 61B</span><span style="width:85.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Part 16</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold"></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>Heading to Part 16</span><span style="width:38.35pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.......</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>rs. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 80</span><span style="width:91.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">................</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>R. 81</span><span style="width:91.89pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">................</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span style="font-weight:bold">Schedule 1</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span></span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R4</span><span style="width:69.5pt; font-family:'Lucida Console', monospace; display:inline-block">............</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R11</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R27</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R27A</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R28</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R29</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R30</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R40</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R48A</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R49A</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R49B</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R53A</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R55A</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R55B</span><span style="width:58.49pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>ad. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R63</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R64</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt"><span>am. 2008 No. 73</span></p></td></tr><tr><td style="width:113.05pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-left:8.9pt; text-indent:0pt"><span>Form R65</span><span style="width:64.49pt; font-family:'Lucida Console', monospace; display:inline-block">...........</span></p></td><td style="width:236.3pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableOfAmend" style="margin-right:0pt; margin-bottom:3pt"><span>am. 2008 No. 73</span></p></td></tr></tbody></table>
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Notice of an appeal is given against [* the decision, award, order or opinion made or act or refusal or failure to make a decision or do an act] by [name of member of the Commission] at [place] on [date] in this matter.
[Set out in numbered paragraphs the grounds including particulars of the grounds on which it is claimed that the matter is of such importance that, in the public interest, leave to appeal should be granted.]
Dated 20
*The applicant must detail the particulars of the matter(s) being appealed by way of specific reference to the categories listed in subsection 120 (1) or 121 (1) of the Act.
Note If it is intended to seek a stay of the whole or part of the award, order or decision pending the determination of the appeal, the notice of appeal must include an application to that effect, as set out below:
Note: ‘Application is also made for an order that the operation of [Set out the whole or part of the award, order or decision] be stayed pending the determination of this appeal or until further order of the Commission.’
Form R2
Rule 13 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN EXTENSION OF TIME FOR INSTITUTING APPEAL
Application is made for an extension of time for instituting an appeal against [* the decision, award, order or opinion made or act or refusal or failure to make a decision or do an act] by [name of member of Commission] at [place] on [date] in this matter.
[Set out in numbered paragraphs the grounds on which it is claimed an extension of time should be granted.]
*The applicant must detail the particulars of the matter(s) being appealed by way of specific reference to the categories listed in subsection 120 (1) or 121(1) of the Act.
Form R3
Rule 15 of the Australian Industrial Relations Commission Rules
NOTICE OF APPEAL UNDER SECTION 147
OF THE ACT
Notice of an appeal is given against [* the decision made or act or refusal or failure to make a decision or do an act] by [name of Registrar] at [place] on [date] in this matter.
[Set out in numbered paragraphs the grounds including particulars of each ground.]
* The appellant must detail the particulars of the matter(s) being appealed.
Note If it is intended to seek a stay of the whole or part of the decision or act concerned pending the determination of the appeal, the notice of appeal must include an application to that effect, as set out below:
Note: ‘Application is also made for an order that the operation of [Set out the whole or any part of the decision or act concerned] be stayed pending the determination of this appeal or until further order of the Commission.’
Form R4
Rule 16 of the Australian Industrial Relations Commission Rules
Notice to Initiate a Bargaining Period (section 423 of the Act)
Initiating Party
The Initiating Party is: (tick one)
an employer
an organisation of employees
an employee acting on his or own behalf and on behalf of other employees
an authorised agent acting on behalf of one or more employees (see Note 1)
The Industry in which the Employer is engaged is:
[Repeat details for each other negotiating party. If the Initiating Party is an employer, then a schedule listing or describing the employees at the time whose employment will be subject to the proposed agreement should be attached ‑ see paragraph 423 (4) (b) of the Act]
TAKE NOTICE that the Initiating Party intends to try to make a collective agreement to which section 423 of the Act applies with the Other Negotiating Party/Parties under section 327 [or section 328] of the Act.
Required Particulars (s 426 of the Act)
(a) the single business or part of the single business to be covered by the proposed collective agreement.
(b) the types of employees whose employment will be subject to the proposed collective agreement and any other persons who will be bound by the proposed collective agreement.
(c) the matters that the initiating party proposes should be dealt with by the proposed collective agreement.
[Please specify. If necessary, a separate document may be attached.]
(d) the proposed nominal expiry date of the proposed collective agreement
[Name] on behalf of [Initiating Party]
Note 1 Where the Initiating Party is acting as an authorised agent for one or more employees the Initiating Party must attach to the notice given to the Commission ‑ but not the notices given to the other negotiating parties ‑ a document stating the names of those employee(s): see subsection 424 (2) of the Act.
Note 2 The bargaining period begins at the end of 7 days after the date on which the last person served with the notice was so served: see section 427 of the Act.
Form R5
Rule 17 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER TO RESTRICT THE INITIATION OF A NEW BARGAINING PERIOD
(section 429 of the Act)
IN the matter of a former bargaining period between [names of former negotiating parties]
arising in matter [the former bargaining period case number].
Application is made for an order of the Commission to:
not allow the initiation of a new bargaining period or
attach conditions to any new bargaining period.
[Set out in numbered paragraphs the grounds and particulars of the grounds, including the basis upon which the application is made under subsection 429 (4) or (5) of the Act]
[A copy of the notice under paragraph 428 (b) of the Act must be attached.]
Form R6
Rule 18 of the Australian Industrial Relations Commission Rules
Application for an Order to Suspend or Terminate a Bargaining Period
(sections 430 to 433 of the Act)
[repeat details for each party]
The business or part of business to which the application relates:
The Bargaining Period(s) to which the application relates (optional):
Note The Applicant does not have to specifically identify the bargaining periods to which this application relates: subsection 430 (10) of the Act. However, it would assist the expeditious resolution of this application if the ‘BP’ matter number(s) are included here or copies of the relevant notice(s) initiating a bargaining period are attached to this application.
Application is made to suspend and/or terminate:
the above specified bargaining period(s), or
whatever bargaining periods apply to the above specified business or part thereof.
Circumstance(s) relied upon by Applicant:
Please tick one or more boxes:
subsection 430 (2) of the Act — Failure to genuinely try and reach agreement etc.
subsection 430 (3) of the Act — Industrial action endangering life etc
subsection 430 (7) of the Act — Employees are not members nor eligible to be members of organisation
subsection 430 (8) of the Act — Demarcation dispute
section 431 of the Act — Pattern bargaining
section 432 of the Act — ‘Cooling off’ ‑ suspension would assist in resolving matters at issue
section 433 of the Act — Significant harm to a third party
Particulars of the circumstance(s):
[Please give a brief description of the facts alleged to constitute the specified circumstance(s)]
Form R7
Rule 18 of the Australian Industrial Relations Commission Rules
Application for an Order for an Extension of a Suspension of a Bargaining Period
(subsections 432 (3) and s 433 (4) of the Act)
[repeat details for each party]
The Applicant applies for an extension of the suspension of the bargaining period ordered by:
[insert the name of the member who made the order]
On [date]
in Print [PR [insert print number of order] ]
copy attached.
The period of the extension of suspension sought is: [insert duration]
Circumstances that make an extension of the suspension appropriate (paragraph 432 (3) (b) and paragraph 433 (4) (b) of the Act):
[Please give a brief description of the basis on which the Commission ought be satisfied that an extension of the suspension is appropriate]
Note A COPY OF THIS APPLICATION MUST BE SERVED ON OTHER NEGOTIATING PARTIES.
Form R8
Rule 19 of the Australian Industrial Relations Commission Rules
NOTICE UNDER SUBSECTION 430 (6) OF THE ACT
Matter No:
[insert matter No.]
To:
[list all negotiating parties]
The Commission has made an Order under subsection 430 (1) and (3) of the Act.
[PR [insert print number ] ]
terminating the bargaining period between the parties on the basis that industrial action is threatening or would threaten to
[complete as appropriate: ‘endanger the life, the personal safety or health, or the welfare, of the population or of part of it’ and/or ‘cause significant damage to the Australian economy or an important part of it’].
The effect of Division 8 of Part 9 of the Act is that the Commission must make a Workplace Determination in accordance with section 503 and section 504 of the Act if the parties are unable to resolve their differences in the negotiating period provided for in section 502 of the Act.
A Workplace Determination made by the Commission will bind the negotiating parties and all employees whose employment is subject to the determination as if it were a collective agreement in operation. It will contain terms that, in the opinion of the Full Bench that makes the determination, deal with the matters at issue between the parties. The Workplace Determination must not contain any terms other than those required by section 504 of the Act.
You are advised that you, the negotiating parties, may agree to submit the matters at issue between the parties to an alternative dispute resolution process conducted by the Commission or another provider (Part 13 of the Act).
If all negotiating parties agree that they wish to submit the matters in issue between the parties to an alternative dispute resolution process conducted by the Commission the parties should complete the attached form of application to have the Commission conduct a dispute resolution process and forward it to the Commission by facsimile to [fax number] or by email to [email address].
Date 20 .
[signature of member]
COMMISSIONER [or as appropriate]
Form R9
Rule 19 of the Australian Industrial Relations Commission Rules
NOTICE UNDER SUBSECTION 432 (6) OF THE ACT
Matter No:
[insert matter No.]
To:
[list all negotiating parties]
[EITHER]
The Commission has made an order under subsection 432 (1) of the Act.
[PR [insert print number] ]
suspending the bargaining period between the parties.
The Commission has made an order under subsection 432 (3) of the Act.
[PR [insert print number] ]
extending the suspension of the bargaining period between the parties.
[AND]
The negotiating parties may agree to submit the matters at issue between the parties to an alternative dispute resolution process conducted by the Commission or another provider (Part 13 of the Act).
If all negotiating parties agree that they wish to submit the matters in issue between the parties to an alternative dispute resolution process conducted by the Commission the parties should complete the attached form of application to have the Commission conduct a dispute resolution process and forward it to the Commission by facsimile to [fax number] or by email to [email address].
Date 20 .
[signature of member]
COMMISSIONER [or as appropriate]
Form R10
Rule 20 of the Australian Industrial Relations Commission Rules
NOTICE OF THE GIVING OF AUTHORISATION TO ENGAGE IN INDUSTRIAL ACTION
IN the matter of a bargaining period between
[names of negotiating parties]
arising in matter [bargaining case number]
Under paragraph 446 (1) (c) of the Act, notice is given to the Registrar that the members of [name of organisation of employees]
have been authorised to engage in industrial action, within the bargaining period, against [name of particular employer].
The authorisation was given by [name of the relevant committee of management of the organisation or person authorised by that committee to authorise the action]
in accordance with:
[Insert reference to the rule under which the action is authorised, if the organisation’s rules provide for how industrial action is to be authorised].
[Signature of person giving notice]
Form R11
Rule 21 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER FOR A PROTECTED ACTION BALLOT TO BE HELD
(Section 451 of the Act)
Is the applicant acting as agent for an employee or employees?
If the applicant is an employee or group of employees, does the application have the support of at least the prescribed number of employees (subsection 451 (4) of the Act)?
Note For the following groups of employees, the prescribed number is:
Note: (a) fewer than 80 employees — 4 employees;
Note: (b) 80 to 5 000 employees — 5% of employees;
Note: (c) more than 5 000 employees — 250 employees.
Is there any existing collective agreement, binding on employees who will be subject to the proposed new agreement, with a nominal expiry date that has not yet passed (subsection 451 (2) of the Act)?
Employer
The application relates to a proposed protected action ballot among employees of the following employer:
Questions to be put, including the nature of industrial action proposed (paragraph 452 (1) (a) of the Act)
[set out the question(s) to be put in the ballot, including the nature of the industrial action]
Types of employees to be balloted (paragraph 452 (1) (b) of the Act)
[set out details of the types of employees to be balloted]
Proposed Authorised Ballot Agent (see subsection 452 (2) and section 480 of the Act) — (optional)
Australian Electoral Commission.
The Applicant
Proposed Authorised Independent Adviser (see paragraph 463 (1) (e) and section 481 of the Act)
If the Applicant has nominated him, her or itself to conduct the ballot, the person nominated by the Applicant to be the authorised independent adviser for the ballot:
Additional information:
Estimate of number of employees eligible to be balloted:
Describe briefly the approximate number and location of worksites at which employees work:
Other circumstances relevant to what may be appropriate orders and directions for the Commission to issue in conjunction with the application:
[eg shift patterns or usual modes of communication with employees that may affect how effective notification to employees may occur]
Attachments (subsections 453 (1) and (3) of the Act)
The following documents are attached and marked as indicated:
‘A’ A copy of the notice under section 423 of the Act initiating a bargaining period with the employer. [attach a copy of the notice]
‘B’ A copy of the particulars that accompanied that notice.
[attach a copy of the particulars required by section 426 of the Act]
‘C’ If the applicant is an organisation of employees, a written notice showing that the application has been duly authorised by a committee of management of the organisation or by someone authorised by such a committee to authorise the application.
[attach a copy of the notice]
‘D’ A declaration complying with subsection 453 (4) and Chapter 2, Regulation 9.7, of the Workplace Relations Regulations 2006.
[attach a copy of the declaration]
and, where the applicant is acting as agent for one or more employees,
‘E’ a copy of the names of the employee(s) represented by the applicant as agent (subsection 453 (3) of the Act). [attach a copy of the list of names]
Note A copy of this application including the attachments (but not Attachment E) must be served on the employer and any person nominated to conduct the ballot within 24 hours of lodging this application with the commission (section 454 of the Act).
DECLARATION BY APPLICANT FOR A PROTECTED ACTION BALLOT ORDER
Subsections 453 (1) and (4) of the Act and Chapter 2, regulation 9.7 of the Workplace Relations Regulations 2006
Giving false or misleading information is a serious offence.
[See section 137.1 of the Criminal Code].
[EITHER]
On
[insert date]
I
[insert name]
of,
[insert address]
under subsection 453 (1) of the Workplace Relations Act 1996 declare that the industrial action to which the application relates is not for the purpose of supporting or advancing claims to include in the proposed collective agreement any prohibited content.
On
[insert date]
I
[insert name]
of,
[insert address]
under subsection 453 (1) of the Workplace Relations Act 1996 declare that the industrial action to which the application relates does not involve claims for prohibited content.
Declared by me at [insert place]
[Signature of declarant]
Form R13
Rule 22 of the Australian Industrial Relations Commission Rules
APPLICATION FOR A DECLARATION THAT A PERSON IS ENTITLED TO BE INCLUDED ON THE ROLL OF VOTERS FOR A PROTECTED ACTION BALLOT
(Subsection 468 (2) of the Act)
Protected Action Ballot Order to which this application relates
a copy of which is attached.
The Applicant(s) apply for a declaration that each is entitled to have his or her name included in the roll of voters for the protected action ballot to be held under the Ballot Order.
The basis upon which the Applicants contend that their names should be included on the roll of voters is:
[briefly specify basis for contention as to entitlement to be included on the roll of voters]
Note A copy of this application must be served on the negotiating parties, the authorised ballot agent and the independent adviser, if any, nominated in the ballot order.
Form R14
Rule 22 of the Australian Industrial Relations Commission Rules
APPLICATION FOR A DECLARATION THAT A PERSON IS NOT ENTITLED TO BE INCLUDED ON THE ROLL OF VOTERS FOR A PROTECTED ACTION BALLOT
(Subsection 468 (3) of the Act)
Protected Action Ballot Order to which this application relates
a copy of which is attached.
Capacity in which applicant applies
The Applicant is (tick one):
a negotiating party
the authorised ballot agent
a person whose name appears on the roll of voters prepared in connection with the ballot to which the Ballot Order relates.
Person(s) challenged
The Applicant applies for a declaration that the following persons are not entitled to have their names included on the roll of voters for the protected action ballot to be held under the Ballot Order:
[list names voters being challenged and contact details]
The basis upon which the Applicant contends that the names of these persons should not be included on the roll of voters is:
[briefly specify basis for challenge to inclusion on the roll of voters]
Note A copy of this application must be served on the negotiating parties, the authorised ballot agent and the independent adviser, if any, nominated in the ballot order.
Form R15
Rule 23 of the Australian Industrial Relations Commission Rules
APPLICATION FOR A VARIATION TO A PROTECTED ACTION BALLOT ORDER
(Section 469 of the Act)
The Applicant for a variation is (tick one)
the applicant for the original protected ballot order
the authorised ballot agent
The Applicant for a variation applies for a variation of the protected action ballot order made by
[insert name of the member who made the order]
on [insert date]
in [PR [insert print number of order] ]
a copy of which is attached. [attach copy of order]
The variations sought are:
[specify the variations sought]
The reasons for the variation
[briefly outline the reasons for the variation]
Form R16
Rule 23 of the Australian Industrial Relations Commission Rules
APPLICATION TO REVOKE A PROTECTED ACTION BALLOT ORDER
(Section 470 of the Act)
Is the applicant acting as agent for an employee or employees?
The Applicant applies for a revocation of the protected action ballot order made by
[insert name of the member who made the order]
on [insert date]
in [PR [insert print number of order] ]
a copy of which is attached. [attach copy of order]
[Signature of applicant/s]
Form R17
Rule 24 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER TO STOP OR PREVENT INDUSTRIAL ACTION
* industrial action engaged in by [insert names of parties against whom order is sought] in respect of work carried out by employees of [insert name of employer]
Application is made for an order under subsection 496 (4)* or subclause 51 (2) of Schedule 6* to the Act in the following terms:
[Set out terms of order]
[Set out the grounds in numbered paragraphs, including details of:
the industrial action which is happening, or is threatened, impending or probable; and
how the applicant is a person affected, or likely to be affected (directly or indirectly), by the industrial action.]
* omit whichever is inappropriate
To:
*each person in the application against whom an order is sought, and
*such other person or persons, as the Commission directs.
You are hereby notified that the abovementioned application will be heard by the Commission
on [date],
at [place],
Form R18
Rule 25 of the Australian Industrial Relations Commission Rules
APPLICATIONS TO VARY, REVOKE OR SUSPEND AN AWARD OR ORDER
(Sections 119, 553, 554, 556, 557, 558, 559, 560, 566 and 812 of the Act)
IN the matter of:
[Title of Award]
Application is made for the *variation/*revocation or suspension of the abovementioned award or order in the following terms:
[Set out the terms of the variation or revocation sought]
Indicate the section or sections of the Act relied upon to make this application:
s 119
s 553
s 554
s 556
s 557
s 558
s 559
s 560
s 566
s 812
_________________
To the employers, employees and organisations bound by the abovementioned award:
Form R19
Rule 26 of the Australian Industrial Relations Commission Rules
APPLICATION TO VARY OR REVOKE A TRANSITIONAL AWARD
(Clauses 29, 30 and 31of Schedule 6 to the Act)
IN the matter of:
[Title of Transitional Award]
Application is made for the *variation/*revocation of the abovementioned transitional award in the following terms:
[Set out the terms of the variation or revocation sought]
Indicate the clause or clauses relied upon to make this application:
clause 29 of Schedule 6 to the Act
clause 30 of Schedule 6 to the Act
clause 31 of Schedule 6 to the Act
__________________
To the persons and organisations bound by the abovementioned transitional award:
Form R20
Rule 27 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER FOR A TRANSITIONAL AWARD TO CEASE TO BE BINDING
(Clauses 58 and 59 of Schedule 6 to the Act )
IN the matter of:
[Title of Transitional Award]
Application is made for an order to cease to be bound by the abovementioned transitional award in the following terms:
[Set out the terms of the Order sought]
Indicate the clause or clauses relied upon to make this application:
clause 58 of Schedule 6 to the Act
clause 59 of Schedule 6 to the Act
___________________
To the employers, employees and organisations bound by the abovementioned transitional award:
NOTICE OF HEARING OF APPLICATION TO VARY A COMMON RULE AWARD
AND in the matter of an application to vary the abovementioned award.
Notice is given:
(a) that this matter involves the variation of the term (or each of the terms) of the above‑mentioned award referred to in the Schedule below; and
(b) that the term (or each of the terms) so referred to is (or are) a common rule in Victoria for the \[specify industry\] industry, in relation to employers and employees within the meaning of section 858 of the Workplace Relations Act 1996; and
(c) the matter will be heard
before \[name\]
A copy of the award (or order) may be inspected free of charge at the Australian Industrial Registry at [address]
AND in the matter of the variation of the above award(s).
Notice is given
(a) that the Commission has varied the term (or terms) of the above‑mentioned award(s) referred to in the Schedule below; and
(b) that the variation(s) will be a common rule in Victoria for the \[specify industry\] industry, in relation to employers and employees within the meaning of section 858 of the Workplace Relations Act 1996; and
(c) that any organisation or person interested and having an objection to the variation(s) binding that person or organisation and wanting to be heard in relation to the abovementioned variation is invited to lodge with the Commission a notice of that objection.
A copy of the award(s) may be inspected free of charge at the office of the Australian Industrial Registry
at [address]
or at the office of the Australian Industrial Registry in any capital city.
SCHEDULE OF TERMS TO BE VARIED
Print Number
Award code and variation number
Clause number
Subject
Substance of variation
Date of effect
Note The prescribed time for lodging an objection to a variation is 28 days after the publication of this notice.
Form R23
Rule 28 of the Australian Industrial Relations Commission Rules
NOTICE OF OBJECTION TO VARIATION OF A COMMON RULE
AND in the matter of an application to vary the above award [or part thereof].
Notice is given of an objection to the variation binding
[name of organisation or person interested].
[Set out in numbered paragraphs the grounds of objection].
Note The prescribed time for lodging an objection to a variation is 28 days after the publication of this notice.
DECLARATION OF COMMON RULE APPLICATION NOT BINDING ON ORGANISATION OR PERSON
AND in the matter of the variation of the abovementioned award
Notice is given
(a) that, on \[date\] the Commission varied the term (or terms) of the above‑mentioned award referred to in the Schedule below; and
(b) that the variation is (or will be) a common rule in Victoria for the \[specify industry\] industry, in relation to employers and employees within the meaning of section 858 of the Workplace Relations Act 1996; and
(c) that, on \[date\] the Commission, in accordance with
subclause 85(5) of Schedule 13 of the Workplace Relations Act 1996
or
subsection 142(6) of the pre‑reform Workplace Relations Act 1996 as it continues to apply because of clause 84 of Schedule 6 to the Workplace Relations Act 1996,
declared that the variation (or part thereof) is not binding on
\[person or organisation\].
SCHEDULE
TERMS TO BE VARIED
Print Number
Clause No.
Subject
Substance of variation
Form R25
Rule 29 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDER REQUIRING EQUAL REMUNERATION FOR WORK OF EQUAL VALUE
(Sections 624 and 625 of the Act)
Application is made for the making of an order for employee(s) covered by the order that there will be equal remuneration for work of equal value.
The order sought is:
[Set out the terms of the proposed order including the employee(s) to be covered by the order]
[Set out in numbered paragraphs the grounds including particulars of the grounds on which it is claimed that no adequate alternative remedy exists under section 625 of the Act]
No proceedings for an alternative remedy have begun under another provision of the Act or under another law of the Commonwealth or under a law of a State or Territory/Proceedings or the proceedings for an alternative remedy have been discontinued or failed for want of jurisdiction.*
The following trade unions and employer organisations or associations may, to the best of the knowledge and belief of the applicant, have an interest in the matter:
[Set out trade unions and employer organisations or associations which may have an interest in the matter]
The following employer(s) may, to the best of the knowledge and belief of the applicant, have an interest in the matter:
[Set out employer(s) who may have an interest in the matter]
Form R26
Rule 29 of the Australian Industrial Relations Commission Rules
NOTICE OF CONCILIATION OR HEARING FOR APPLICATION FOR ORDER FOR EQUAL REMUNERATION FOR WORK OF EQUAL VALUE
(Sections 624 and 625 of the Act)
[case number]
Notice is given–
(a) that on \[date\] the Commission received an application for an order for equal remuneration for work of equal value in respect of the undermentioned employee(s):
\[Set out employee(s) to be covered\];
(b) that the matter will be conciliated/heard \[delete as appropriate\]
before \[name of Commission Member\]; and
(c) that each trade union whose rules entitle it to represent the industrial interests of any of the employees concerned and each organisation or association representing employers of any of those employees and wishing to be heard in relation to the application is invited to attend the Commission on the abovementioned date; and
(d) that any employer of employees to be covered by the order and wishing to be heard in relation to the application is invited to attend the Commission on the abovementioned date.
A copy of the application may be inspected at the Australian Industrial Registry at [address] free of charge.
Form R27
Rule 30 of the Australian Industrial Relations Commission Rules
APPLICATION FOR RELIEF IN RELATION TO TERMINATION OF EMPLOYMENT
If this application was prepared by a legal practitioner, has a contingency fee agreement [see section 656 of the Act] been entered into?
If this application was prepared by a representative other than a legal practitioner, has a costs arrangement [see section 656 of the Act] been entered into? Yes No
See next page for lodgement fee details
Commission Matter No. U___________________
Fee Section 644 of the Workplace Relations Act 1996 requires a fee to be paid on lodgment of this application with the Commission unless a Registrar has, in effect, approved the waiving of the fee.If an application is lodged by facsimile transaction, credit card details must be provided for payment of the fee (if any).If an application is lodged electronically in accordance with Rule 69, credit card details must not be provided on this form. Payment of the fee (if any) can only be made via the Commission’s Internet page at http://www.airc.gov.au. Cash Cheque/money order (to be made payable to Collector of Public Monies, Australian Industrial Registry) Visa MasterCardCard Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __Card Expiry Date __ __ / __ __Cardholder’s Name ………………………………………….....Signature ...………………………………………………………Any refund of the lodgement fee (see subsection 644 (8) of the Act) will be forwarded to the applicant at the address nominated in item 2.
Commission use onlyReceipt Number: ........................................ / Credit TransactionProcessed: ..................................................
Note A copy of this completed form (and any attachments) will be forwarded to your former employer.
Form R27A
Rule 30 of the Australian Industrial Relations Commission Rules
APPLICATION FOR RELIEF IN RELATION TO TERMINATION OF EMPLOYMENT
This Form is to be completed by an applicant union in respect of an application for relief in relation to termination of employment on the ground or grounds of an alleged contravention of one or more of sections 659, 660 and 661 of the Workplace Relations Act 1996.
If this application was prepared by a legal practitioner, has a contingency fee agreement (see section 656 of the Act) been entered into?
If this application was prepared by a representative other than a legal practitioner, has a costs arrangement (see section 656 of the Act) been entered into?
See next page for lodgement fee details
Commission Matter No. U___________________
Fee Section 644 of the Workplace Relations Act 1996 requires a fee to be paid on lodgment of this application with the Commission.If an application is lodged by facsimile transaction, credit card details must be provided for payment of the fee (if any).If an application is lodged electronically in accordance with Rule 69, credit card details must not be provided on this form. Payment of the fee (if any) can only be made via the Commission’s Internet page at http://www.airc.gov.au. Cash Cheque/money order (to be made payable to Collector of Public Monies, Australian Industrial Registry) Visa MasterCardCard Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __Card Expiry Date __ __ / __ __Cardholder’s Name ………………………………………….....Signature ...………………………………………………………Any refund of the lodgement fee [see subsection 644 (8) of the Act] will be forwarded to the applicant at the address nominated in item 2.
Commission use onlyReceipt Number: ........................................ / Credit TransactionProcessed: ..................................................
Note A copy of this completed form (and any attachments) will be forwarded to your former employer.
PLEASE RETAIN A COPY OF THIS DOCUMENT
FOR YOUR OWN RECORDS
Form R28
Rule 31 of the Australian Industrial Relations Commission Rules
NOTICE OF EMPLOYER’S APPEARANCE
If this notice was prepared by a legal practitioner, has a contingency fee agreement [see section 656 of the Act] been entered into?
If this notice was prepared by a representative other than a legal practitioner, has a costs arrangement [see section 656 of the Act] been entered into? Yes No
Note This form must be lodged with the Commission within 7 days of receipt of Form R27 or R27A. As soon as practicable after lodging the form, the employer must give a copy of the form to the applicant.
Form R29
Subrule 31 (3) of the Australian Industrial Relations Commission Rules
NOTICE OF MOTION TO DISMISS THE APPLICATION FOR WANT OF JURISDICTION
(Section 645 of the Act)
Commission Case/File Number: U
The employer moves for the dismissal of the employee’s application on the following jurisdictional ground(s):
[Write here and/or attach document(s)]
Summary of facts in support of ground(s):
[Write here and/or attach document(s)]
Particular cost that would be caused to the business of the employer in attending a hearing
Specify the cost to the business of the employer in attending a hearing on this motion to dismiss the employee’s application on the above stated grounds:[Write here and/or attach document(s)]
Objection to conciliation occurring before this motion is dealt with
Does the employer object to conciliation before this motion is dealt with by the Commission? Yes No
Note A motion to dismiss the application for want of jurisdiction is taken to have been made on the date of filing. The employer must serve a copy of the notice of motion on the applicant as soon as practicable after the notice of motion has been filed.
Form R30
Subrule 31 (4) of the Australian Industrial Relations Commission Rules
NOTICE OF MOTION TO DISMISS THE APPLICATION AS FRIVOLOUS, VEXATIOUS OR LACKING IN SUBSTANCE
(Section 646 of the Act)
Note A motion to dismiss the application on the ground that it is frivolous, vexatious or lacking in substance is taken to have been made on the date of filing. The employer must serve a copy of the notice of motion on the applicant as soon as practicable after the notice of motion has been filed.
Form R31
Rule 32 of the Australian Industrial Relations Commission Rules
NOTICE OF REPRESENTATIVE’S APPEARANCE
and
Name of representative entering appearance*/ change of appearance*
Name of contact person (if different from name of representative):
Address for service of representative:
Phone ( )
Fax ( )
Email:
Appearance is entered on behalf of applicant*/respondent*.
Please indicate whether the representative is
a legal practitioner:
If so, has the representative been retained by the party for whom the appearance is entered under a contingency fee agreement as to the practitioner’s costs? Yes No
a representative other than a legal practitioner:
If so, has the representative been retained by the party for whom the appearance is entered under a costs arrangement (as defined in subsection 656 (5) of the Act) as to the representative’s costs? Yes No
Signature of representative:
Date of this Notice: / /
Note As soon as practicable after filing the notice, a copy must be given to the other party.
Form R32
Rule 36 of the Australian Industrial Relations Commission Rules
NOTICE OF DISCONTINUANCE
(Subsection 643 (16) of the Act)
and
The Applicant
*wholly discontinues this matter
*wholly discontinues this matter as part of the terms of settlement agreed to.
Dated:
Signed:
[applicant/legal firm/union or other representative]
Note As soon as practicable after filing this notice in the industrial registry a copy of this notice must be given to the employer.
Form R33
Rule 37 of the Australian Industrial Relations Commission Rules
NOTICE OF ELECTION TO PROCEED TO ARBITRATION OR TO BEGIN COURT PROCEEDINGS
(Section 651 of the Act)
and
Under section 651 of the Act and further to the certificate issued by the Commission under subsection 650 (2) on [date of certificate], the Applicant elects as follows:1
(Indicate your election by marking the appropriate box or boxes)
A. The Applicant elects to proceed to arbitration in the Commission on the ground that the termination of his or her employment was harsh, unjust or unreasonable within the meaning of paragraph 643 (1) (a) of the Act.2
B. The Applicant elects to begin proceedings in the Federal Court of Australia or the Federal Magistrates Court for an order under section 665 of the Act in respect of the contraventions of section 659 of the Act (discrimination etc.) or section 660 of the Act (failure to notify Centrelink ) alleged in the application.
C. The Applicant elects to begin proceedings in a court of competent jurisdiction for an order under section 665 of the Act in respect of the contravention of section 661 of the Act (employer to give notice of termination) alleged in the application.
D. The Applicant elects to do none of the above.
[signature]
Applicant [or Applicant’s legal firm, union or other representative]
NOTES:
1. See section 651 of the Act in relation to the election an applicant must make after receiving a certificate under subsection 650 (2) of the Act.
2. An applicant cannot make both elections ‘A’ and ‘B’.
3. The applicant has 7 days from the date the certificate under subsection 650 (2) of the Act is issued to lodge this Notice of Election in the Industrial Registry (or 28 days if the certificate identifies the ground of an alleged contravention of section 659 of the Act as a ground on which conciliation is, or is likely to be, unsuccessful). The Notice of Election can be lodged either personally, or by post, facsimile transmission or email. THE APPLICATION FOR RELIEF IN RESPECT OF TERMINATION OF EMPLOYMENT WILL BE TAKEN TO HAVE BEEN DISCONTINUED IF THE NOTICE OF ELECTION IS NOT LODGED WITHIN THAT PERIOD. The Commission is not permitted to extend time for lodging a Notice of Election required to be lodged within 7 days — see subsection 651 (8) of the Act.
4. As soon as possible after lodging this notice in the Industrial Registry a copy of this notice must be given to the employer.
5. In the event that an applicant elects to begin court proceedings, the lodgment of this Notice of Election in the Industrial Registry will not have the effect of commencing any such court proceedings. Consequently, in addition to the lodgment of this Form in the Industrial Registry (and the giving of a copy to the employer), the applicant must commence such proceedings before an appropriate court within 14 days after the lodgment of an election under subsection 651 (6) of the Act, or within such period as a court allows on an application made during or after those 14 days. There is no requirement to include the document entitled ‘ASSESSMENT OF MERITS ACCOMPANYING A CERTIFICATE ISSUED UNDER SECTION 650 OF THE ACT’ when lodging an application in a court under section 663 of the Act.
Form R34
Rule 38 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDER FOR COSTS
(Section 658 of the Act)
and
Details of Applicant
1. Name of applicant[person seeking an order for costs]
2. Address to which documents should be sent
Postcode:
3. Phone or fax number(s)
Business hours ( )After hours ( )Mobile:Fax ( )Email:
Details of any Representative of Applicant
4. Name of legal firm, union, employer organisation or other representative
5. Name of contact person at legal firm, union, employer organisation or other representative
6. Contact details of legal firm, union, employer organisation or other representative
Postcode:Phone ( ) Fax ( )Email:
Application is made for an order for costs incurred in respect of an application under section 643 of the Act.
The order is sought under
[insert the particular subsection or subsections of section 658 of the Act that is or are applicable]
against
[insert name of party and/or representative against whom order is to be made ]
[Write here or attach document setting out in numbered paragraphs the grounds upon which the application for costs is based]
Form R35
Rule 39 of the Australian Industrial Relations Commission Rules
APPLICATION FOR SECURITY FOR THE PAYMENT OF COSTS
(Section 658 of the Act)
and
Details of Applicant
1. Name of applicant[person seeking an order for security for the payment of costs]
2. Address to which documents should be sent
Postcode:
3. Phone or fax number(s)
Business hours ( )After hours ( )Mobile:Fax ( )Email:
Details of any Representative of Applicant
4. Name of legal firm, union, employer organisation or other representative
5. Name of contact person at legal firm, union, employer organisation or other representative
6. Contact details of legal firm, union, employer organisation or other representative
Postcode:Phone ( ) Fax ( )Email:
Application is made for an order for security for the payment of costs.
The order is sought in respect of
[insert the particular application under section 643 of the Act or the particular proceedings begun in relation to an application under section 643 of the Act (see subsection 658 (10) of the Act), as the case may be, for which the order is sought]
against
[name of party against whom order is to be made]
[Write here or attach document setting out in numbered paragraphs the grounds upon which the application for security for the payment of costs is based]
Form R36
Rule 40 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDER IF EMPLOYER FAILS TO INFORM OR CONSULT TRADE UNION ABOUT TERMINATION
(Subsection 668 (2) of the Act)
Details of Applicant
1. Name of applicant[employee or trade union]
2. Address to which documents should be sent
Postcode:
3. Phone or fax number(s)
Business hours ( )After hours ( )Mobile:Fax ( )Email:
Details of any Representative of Applicant
4. Name of legal firm, union or other representative
5. Name of contact person at legal firm, union or other representative
6. Contact details of legal firm, union or other representative
Postcode:Phone ( ) Fax ( )Email:
Details of Employer
7. Name of employer’s business, company, corporation, authority or agency
8. Details of contact person
9. Employer’s trading address or registered office
Postcode:Phone ( ) Fax ( )Email:
Application is made for an order against the employer under subsection 668 (2) of the Act.
[Write here or attach document setting out in numbered paragraphs the grounds, including the particulars of the grounds, on which it is claimed that no alternative remedy exists within the meaning of section 671 of the Act]
Form 5
of Schedule 1 to the Workplace Relations Regulations 2006
(appended here for ease of reference)
Form 5
Workplace Relations Regulations 2006
Regulation 13.2
APPLICATION TO HAVE A DISPUTE RESOLUTION PROCESS CONDUCTED
| [Name of applicant] |
applies to the Commission to have a dispute resolution process conducted under Division
[insert Division No. 3, 4 or 5]
of Part 13 of the Workplace Relations Act 1996.
The matter in dispute relates to:[description of matters in dispute].
Note Identify:
Note: (a) the provision(s) in the Workplace Relations Act to which the dispute relates (for example, a particular entitlement that is guaranteed by the Australian Fair Pay and Conditions Standard); or
Note: (b) the award or workplace agreement to which the dispute relates.
The parties to the matter in dispute are [description of parties].
Note If the application relates to collective bargaining negotiations, identify the other persons or organisations with whom you propose to reach an agreement.
The following steps of the dispute settling process have been taken:
[List the steps taken and enclose a copy of the dispute settling process].
The type(s) of assistance sought from the AIRC is or are:
[Describe the assistance].
Note The types of assistance that the AIRC might provide can be varied by agreement while the dispute resolution process is underway.
Dated
[Applicant’s signature]
Form R37
Subrule 41 (2) of the Australian Industrial Relations Commission Rules
APPLICATION to have a dispute resolution process conducted — pre‑reform instrument (certified agreement or australian workplace agreement)
and
Other relevant party(s) to the dispute
Application is made to the Commission to have a dispute resolution process conducted under the following agreement:
[Name of Agreement]
Type of Agreement: Certified Agreement
Australian Workplace Agreement
The dispute settlement procedure is at clause(s):
[specify clause(s) and attach copy]
The matter(s) in dispute relate(s) to:
[description of matter(s) in dispute].
The dispute relates to the application of the following clause(s) of the agreement: [specify clause(s)]
The following steps of the dispute settlement procedure have been taken:
[List the steps taken].
Note: Dated 20 .
Note: [Applicant’s signature]
Form R38
Rule 42 of the Australian Industrial Relations Commission Rules
NOTIFICATION TO INDUSTRIAL REGISTRAR THAT PARTIES ARE UNABLE TO AGREE ON WHO IS TO CONDUCT ALTERNATIVE DISPUTE RESOLUTION PROCESS
(Subsection 696 (3) of the Act)
TO: THE INDUSTRIAL REGISTRAR
Other Parties to dispute:
[Repeat details for each other negotiating party]
Under subsection 696 (3) of the Act, notice is given that the following parties are conducting a dispute resolution process in accordance with the Model Dispute Resolution Process in Division 2 of Part 13 of the Act and cannot agree on who is to conduct the alternative dispute resolution process.
Nature of the Dispute:
[Brief description of the nature of the dispute]
The provision of the Workplace Relations Act or the term of the award, workplace agreement or workplace determination by which the model dispute resolution process applies to the dispute (see subsection 694 (2)):
[identify the provision or term]
[Name] on behalf of [Notifying Party]
Form R39
Rule 43 and 44 of the Australian Industrial Relations Commission Rules
NOTIFICATION OF AN ALLEGED INDUSTRIAL DISPUTE
(Clause 33 of Schedule 6 to the Act)
You are notified of the existence of an alleged industrial dispute between:
and
Other party(s) to the industrial dispute*
concerning
[*matters in dispute including any claims]
Transitional awards binding on the parties to the dispute are
[Insert the titles of the awards]
State whether industrial action has been taken, is being taken or is threatened.
**The Commission is asked to deal with this matter on the basis of an earlier finding of dispute in matter C .
* The original and 2 copies of the notification of an alleged industrial dispute arising from the service of a log of claims should be accompanied by 2 copies of:
‑ the letter of demand;
‑ the log of claims;
‑ the list of persons served in accordance with the Rules of the Commission;
‑ a statement as to service by a person having knowledge of the facts; and
‑ a statement, by an officer having knowledge of the facts and authorised for the purpose by the committee of management of the organisation serving the log of claims, that the letter of demand and log were served with the authority of the organisation;
‑ a statement, by an officer of the organisation serving the log of claims:
(a) that the officer believes each person served is an excluded employer within the meaning of Schedule 6 to the Act; and
(b) that the officer believes each person served is bound by a transitional award(s) within the meaning of Schedule 6 to the Act; and
(c) containing the name of the transitional award or awards.
** Omit if inapplicable.
Form R40
Rule 46 of the Australian Industrial Relations Commission Rules
APPLICATION FOR PERMIT TO ENTER AND INSPECT PREMISES
(Section 740 of the Act and
regulation 15.2 of the Workplace Relations Regulations 2006)
I,
[ name of member of the Committee of Management],
being a member of the Committee of Management of the –
[insert name of organisation*/ transitionally registered State association* ],
an organisation registered under
[Schedule 1 to the Act*]
or
[transitionally registered under Schedule 10 to the Act* ]
apply, under Division 2 of Part 15 of the Act for a Right of Entry permit for the following official (“the proposed permit holder”):‑
Name: [Insert name of official]
Office/Position: [Insert office held or position in which employed]
Declaration by member of committee of management
I, [name] of [address], [office or position]
declare that, having made proper inquiries (including inquiries of the proposed permit holder) and having reviewed the records of the organisation, declare that the proposed permit holder is a fit and proper person to hold a right of entry permit in that, to the best of my knowledge and belief, the proposed permit holder:
(a) has received appropriate training about the rights and responsibilities of a permit holder, namely:
[Describe the training received, its content and the form in which it was delivered. If this is the first permit sought on or after 27 March 2006 you should provide documentary copies of the relevant training material. In subsequent applications it may be sufficient to refer to the material previously provided to the Industrial Registry on [date]].
(b) has never been convicted of an offence against an industrial law;
(c) has never been convicted of an offence against a law of the Commonwealth, a State, a Territory or a foreign country, involving:
(i) entry onto premises; or
(ii) fraud or dishonesty; or
(iii) intentional use of violence against another person or intentional damage or destruction of property;
(d) has never been ordered to pay a penalty under this Act or any other industrial law in respect of his conduct nor has any other person been ordered to pay a penalty in respect of such conduct;
(e) has not had revoked, suspended or been made subject to conditions, any permit issued under Part 15 of the Act or Part IX of the pre‑reform Act;
(f) has not had cancelled, suspended or had imposed conditions on a right of entry for industrial or occupational health and safety purposes, by any court, or other person or body, under a State or Territory industrial law or an OHS law; and
(g) has not been disqualified, by any court, or other person or body, under a State or Territory industrial law or an OHS law, from exercising, or applying for, a right of entry for industrial or occupational health and safety purposes under that law.
[Title of Office]
[Note: adjust declaration as appropriate to reflect the true facts]
Declaration by proposed permit holder
I, [name] of [address], [office or position]
declare that:
(a) I have received the training about the rights and responsibilities of a permit holder referred to in the declaration above.
(b) I have never been convicted of an offence against an industrial law;
(c) I have never been convicted of an offence against a law of the Commonwealth, a State, a Territory or a foreign country, involving:
(i) entry onto premises; or
(ii) fraud or dishonesty; or
(iii) intentional use of violence against another person or intentional damage or destruction of property;
(d) I have never been ordered to pay a penalty under this Act or any other industrial law in respect of his conduct nor has any other person been ordered to pay a penalty in respect of such conduct;
(e) I have not had revoked, suspended or been made subject to conditions, any permit issued under Part 15 of the Act or Part IX of the pre‑reform Act;
(f) I have not had cancelled, suspended or had imposed conditions on a right of entry for industrial or occupational health and safety purposes, by any court, or other person or body, under a State or Territory industrial law or an OHS law; and
(g) I have not been disqualified, by any court, or other person or body, under a State or Territory industrial law or an OHS law, from exercising, or applying for, a right of entry for industrial or occupational health and safety purposes under that law.
[Office/Position]
[Note: adjust declaration as appropriate to reflect the true facts]
Form R41
Rule 47 of the Australian Industrial Relations Commission Rules
APPLICATION FOR REVOCATION OR SUSPENSION OF PERMIT TO ENTER AND INSPECT PREMISES, OR FOR CONDITIONS TO BE IMPOSED ON PERMIT
(Section 744 of the Act and
regulation 15.4 of the Workplace Relations Regulations 2006)
Application is made to
revoke a permit* /
suspend the permit for a specified time*
<specify the period of suspension> /
impose conditions on the permit (whether or not the permit is already suspended*
in respect of
[name of permit holder, office held, name of the organisation/appropriate branch of the organisation].
The grounds on which application is made are as follows:
*Omit if inapplicable
Form R42
Rule 48 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER FOR ACCESS TO NON‑MEMBER RECORDS
(Paragraph 748 (9) (a) of the Act)
Application is made for an order under paragraph 748 (9) (a) of the Act for access to non‑member records in respect of [ insert name of employer and premises ].
Summary of grounds for the order as sought (set out in numbered paragraphs).
Form R43
Rule 49 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN EXEMPTION FROM THE REQUIREMENT TO PROVIDE ENTRY NOTICE
(Section 750 of the Act)
An application is made for an exemption certificate in respect of the entry onto premises under section 750 of the Act to investigate a suspected breach or breaches at the following premises:
Identify the premises to which the application relates:
Set out the particulars of the suspected breach or breaches to the application relates:
State the grounds on which it is alleged that advance notice of entry onto the premises under section 750 of the Act might result in the destruction, concealment or alteration of relevant evidence:
Form R44
Rule 50 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDERS IN RELATION TO ABUSE OF SYSTEM
(Section 770 of the Act)
Application is made against [insert name of organisation, or official of the organisation] for an order under section 770 of the Act for abuse of system.
Summary of grounds for the order as sought (set out in numbered paragraphs).
Form R45
Rule 51 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDERS IN RELATION TO UNREASONABLE REQUESTS BY OCCUPIER OR EMPLOYER AFFECTED
(Section 771 of the Act)
Employer:
Application is made for orders in respect of the rights under subsection 771 (1) of the Act.
Summary of grounds for the order as sought (set out in numbered paragraphs):
Form R46
Rule 52 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDERS IN RELATION TO A DISPUTE ABOUT THE OPERATION OF PART 15 OF THE ACT
(Section 772 of the Act)
Other Party:
Application is made for orders for the purposes of settling disputes about the operation of Part 15 of the Act.
Summary of grounds on which the order is sought (set out in numbered paragraphs):
Is a draft order attached? Yes / No
Form R47
Rule 54 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER IN RELATION TO REPRESENTATION RIGHTS OF ORGANISATIONS OF EMPLOYEES OR TRANSITIONALLY REGISTERED ASSOCIATIONS
(Section 133 of the RAO schedule)
and
(Chapter 6, subregulation 2.1 (3) and 2.4 (1)
of the Workplace Relations Regulations 2006)
Application is made for the following order:
[Set out terms of order sought including detail of the demarcation dispute in relation to which the jurisdiction to make an order is to be exercised]
The following organisations and persons may have an interest in this matter:
[Set out names of organisations, transitionally registered association of employees and persons which may have an interest in this matter]
Form R48
Rule 54 of the Australian Industrial Relations Commission Rules
APPLICATION TO VARY ORDER IN RELATION TO REPRESENTATION RIGHTS OF ORGANISATIONS OF EMPLOYEES OR TRANSITIONALLY REGISTERED ASSOCIATIONS
(Subsection 133 (2) of the RAO schedule)
and
(Chapter 6, regulation 2.2 and subregulation 2.4 (3)
of the Workplace Relations Regulations 2006)
Application is made to vary order*:
[Set out terms of the variation order sought including detail of the demarcation dispute in relation to which the jurisdiction to make an order is to be exercised]
The following organisations and persons may have an interest in this matter:
[Set out names of organisations, transitionally registered associations of employees and persons which may have an interest in this matter]
*attach copy of order to be varied
Form R48A
Rule 54A of the Australian Industrial Relations Commission Rules
APPLICATION FOR TERMINATION OF COLLECTIVE AGREEMENT IN PUBLIC INTEREST AFTER NOMINAL EXPIRY DATE
(Section 397A of the Act)
[title of collective agreement]
Application is made under section 397A of the Act for the abovementioned agreement to be terminated.
The grounds on which this application is made are as follows: [set out in numbered paragraphs the grounds upon which it is claimed that it is not contrary to the public interest to terminate the agreement]
Note If the application is made by an appointed representative of a majority of the employees whose employment is subject to the agreement, the application must be accompanied by a statutory declaration made by the representative which indicates the facts which establish a basis for the Commission to be satisfied that the representative has been appointed by the employees concerned and is acting in accordance with their direction.
To all parties bound by this agreement
You are notified that this application will be heard by [name of member of the Commission]
Form R49
Rule 55 of the Australian Industrial Relations Commission Rules
APPLICATION FOR ORDER TO VARY PRE‑REFORM CERTIFIED AGREEMENT BY A PERSON BOUND BY THE AGREEMENT
(Subsection 170MD (6) of the Pre‑reform Act)
Application is made under subsection 170MD (6) of the pre‑reform Act, as continued in force under paragraph 2 (1) (i) or 13 (1) (k) of Schedule 7 to the Act for an order to vary the abovementioned agreement in the manner set out in the attachment.
________________________
To all persons bound by this agreement.
You are notified that this application will be heard by [name of member of the Commission]
Form R49A
Rule 55 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER TO VARY PRE‑REFORM CERTIFIED AGREEMENT
(Clause 2A of Schedule 7 to the Act)
Application is made under paragraph 2A (1) (b) of Schedule 7 to the Act to vary the terms of the abovementioned agreement in the manner set out in the attachment.
The grounds on which this application is made are as follows: [set out in numbered paragraphs the grounds]
(a) a copy of the variation; and
(b) a statutory declaration made by a person authorised to do so which indicates the facts establishing a basis for the Commission to be satisfied that:
(i) a valid majority of the employees bound by the agreement at the time of making the variation genuinely agree to the variation of the agreement (see subsections 2A (4) and (5) of Schedule 7 to the Act); and
(ii) the agreement as varied would not result, on balance, in a reduction in the overall terms and conditions of employment of the employees bound by the agreement (see paragraph 2A (2) (c) of Schedule 7 to the Act); and
(c) a written statement signed by each party signifying:
(i) their agreement to the variation of the agreement; and
(A) organised or engaged in, or threatened to organise or engage in, industrial action in relation to another party to the agreement; or
Form R49B
Rule 55A of the Australian Industrial Relations Commission Rules
APPLICATION FOR EXTENSION OF PRE‑REFORM CERTIFIED AGREEMENT BY A PERSON BOUND BY THE AGREEMENT
(Clause 2A of Schedule 7 to the Act)
Application is made under paragraph 2A (1) (a) of Schedule 7 to the Act for the extension of the nominal expiry date of the abovementioned agreement from [nominal expiry date] until [date].
Note The application must be accompanied by:
(a) a statutory declaration made by a person authorised to do so which indicates the facts establishing a basis for the Commission to be satisfied that a valid majority of the employees bound by the agreement at the time of making the extension genuinely agree to the extension of the agreement (see subsections 2A (4) and (5) of Schedule 7 to the Act); and
(b) a written statement signed by each party signifying:
(i) their agreement to the extension of the agreement; and
(A) organised or engaged in, or threatened to organise or engage in, industrial action in relation to another party to the agreement; or
Form R50
Rule 56 of the Australian Industrial Relations Commission Rules
APPLICATION FOR APPROVAL OF TERMINATION OF PRE‑REFORM CERTIFIED AGREEMENT
(Section 170MG of the Pre‑reform Act)
Application is made for approval under section 170MG of the pre‑reform Act, as continued in force under paragraph 2 (1) (k) or 13 (1) (n) of Schedule 7 to the Act, for the termination of the abovementioned agreement.
Note: (a) a statutory declaration made by a person authorised to do so which indicates the facts establishing a basis for the Commission to be satisfied that a valid majority of the employees whose employment is subject to the agreement at the time genuinely approve its termination (see subsection 170MG (3) of the pre‑reform Act, as continued in force under paragraph 2 (1) (k) or 13 (1) (n) of Schedule 7 to the Act); and
Note: (b) if one or more organisations are bound by the agreement, a written statement signed by the employer and the one or more organisations signifying their agreement to the termination.
Form R51
Rule 57 of the Australian Industrial Relations Commission Rules
APPLICATION FOR TERMINATION OF PRE‑REFORM CERTIFIED AGREEMENT IN PUBLIC INTEREST AFTER NOMINAL EXPIRY DATE
(Subsection 170MH (1) of the Pre‑reform Act)
Application is made under subsection 170MH (1) of the pre‑reform Act, as continued in force under paragraph 2 (1) (k) or 13 (1) (n) of Schedule 7 to the Act, for the abovementioned agreement to be terminated.
[Set out in numbered paragraphs the grounds upon which it is claimed that it is not contrary to the public interest to terminate the agreement]
Note If the application is made by an appointed representative of a majority of the employees whose employment is subject to the agreement, the application must be accompanied by a statutory declaration made by the representative which indicates the facts which establish a basis for the Commission to be satisfied that the representative has been appointed by the employees concerned and is acting in accordance with their direction.
Form R52
Rule 58 of the Australian Industrial Relations Commission Rules
APPLICATION FOR APPROVAL OF TERMINATION OF PRE‑REFORM CERTIFIED AGREEMENT IN A WAY PROVIDED UNDER AGREEMENT AFTER NOMINAL EXPIRY DATE
Application is made for approval under subsection 170MHA (1) of the pre‑reform Act, as continued in force under paragraph 2(1)(k) or 13(1)(n) of Schedule 7 to the Act, for the termination of the abovementioned agreement.
Note The application must be accompanied by a statutory declaration made by a person authorised to do so which indicates the facts which establish a basis for the Commission to be satisfied that the requirements of paragraphs 170MHA(1) (a) and (b) of the pre‑reform Act, as continued in force under paragraph 2(1)(k) or 13(1)(n) of Schedule 7 to the Act, are complied with.
Form R53
Rule 59 of the Australian Industrial Relations Commission Rules
APPLICATION FOR TERMINATION OF PRE‑REFORM AUSTRALIAN WORKPLACE AGREEMENT IN THE PUBLIC INTEREST AFTER NOMINAL EXPIRY DATE
the Australian workplace agreement between [insert names of parties]
Application is made under subsection 170VM (3) of the pre‑reform Act as it continues to apply because of paragraph 17(1) ( c) of Schedule 7 to the Act, for the abovementioned agreement to be terminated.
[set out in numbered paragraphs the grounds upon which it is claimed that it is not contrary to the public interest to terminate the agreement]
Note Please include full contact details of both parties to the agreement. A copy of the Australian workplace agreement must also accompany this application.
Form R53A
Rule 59A of the Australian Industrial Relations Commission Rules
APPLICATION FOR TERMINATION OF OLD IR AGREEMENT
(Clause 29A of Schedule 7 to the Act)
[title of old IR agreement and code number]
Application is made under subclause 29A(1) of Schedule 7 to the Act for the abovementioned agreement to be terminated.
Note The application must be accompanied by a written statement by each party to the agreement signifying their agreement to the termination.
Form R54
Rule 60 of the Australian Industrial Relations Commission Rules
APPLICATION FOR REVOCATION
OF A SECTION 170MX AWARD
In the matter of [name of section 170MX award]
Application is made under subsection 170MZ (4) of the pre‑reform Act, as continued by paragraph 23(2)(b) of Schedule 7 to the Act, for revocation of the abovementioned award.
Form R55
Rule 61 of the Australian Industrial Relations Commission Rules
REQUEST TO TERMINATE
SECTION 170MX AWARD
In the matter of [name of section 170MX award]
Application is given under subsection 170MZ (5) of the pre‑reform Act, as continued by paragraph 23(2)(b) of Schedule 7 to the Act, requesting the Commission terminate the abovementioned award.
The grounds on which this request is made are as follows:
Form R55A
Rule 61A of the Australian Industrial Relations Commission Rules
APPLICATION FOR EXTENSION OF A PRESERVED COLLECTIVE STATE AGREEMENT BY A PERSON BOUND BY THE AGREEMENT
(Clause 16A of Schedule 8 to the Act)
IN the matter of:[Title of preserved collective State Agreement]
Application is made under paragraph 16A (1) (a) of Schedule 8 for the extension of the nominal expiry date of the abovementioned preserved collective State agreement from [nominal expiry date] until [date].
Note The application must be accompanied by:
(a) a statutory declaration made by a person authorised to do so which indicates the facts establishing a basis for the Commission to be satisfied that a majority of the employees bound by the agreement at the time of making the extension genuinely agree to the extension of the agreement (see paragraphs 16A(2) and (4) of Schedule 8); and
(b) a written statement signed by each party signifying:
(i) their agreement to the extension of the agreement; and
(A) organised or engaged in, or threatened to organise or engage in, industrial action in relation to another party to the agreement; or
Form R55B
Rule 61B of the Australian Industrial Relations Commission Rules
APPLICATION TO VARY A PRESERVED COLLECTIVE STATE AGREEMENT BY A PERSON BOUND BY THE AGREEMENT
(Clause 16A of Schedule 8 to the Act)
IN the matter of:[Title of preserved collective State Agreement]
Application is made under paragraph 16A (1) (b) of Schedule 8 to the Act for the variation of the abovementioned preserved collective State agreement in the following terms:
(a) a copy of the variation; and
(b) a statutory declaration made by a person authorised to do so which indicates the facts establishing a basis for the Commission to be satisfied that:
(i) a majority of the employees bound by the agreement at the time of making the variation genuinely agree
to the variation of the agreement (see subsections 16A (2) and (4) of Schedule 8 to the Act); and
(ii) the agreement as varied would not result, on balance, in a reduction in the overall terms and conditions of employment of the employees bound by the agreement (see paragraph 16A (2) (c) of Schedule 8 to the Act); and
(c) a written statement signed by each party signifying:
(i) their agreement to the variation of the agreement; and
(A) organised or engaged in, or threatened to organise or engage in, industrial action in relation to another party to the agreement; or
Form R56
Rule 62 of the Australian Industrial Relations Commission Rules
APPLICATION TO VARY
A PRESERVED STATE AGREEMENT
(Act, Schedule 8, and Clauses 17 and 18 )
IN the matter of:
[Title of Preserved State Agreement]
Application is made for the variation of the abovementioned preserved State agreement in the following terms:
Sch 8, cl.17
Sch 8, cl.18
To the persons and organisations bound by the abovementioned notional agreement:
Form R57
Rule 63 of the Australian Industrial Relations Commission Rules
APPLICATION TO VARY A NOTIONAL AGREEMENT PRESERVING STATE AWARDS
(Act, Schedule 8, and Clauses 40 and 41)
IN the matter of:
[Title of notional agreement preserving State awards]
Application is made for the variation of the abovementioned notional agreement in the following terms:
Sch 8, cl.40
Sch 8, cl.41
__________________
To the persons and organisations bound by the abovementioned notional agreement:
Form R58
Rule 64 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER AS TO WHETHER AN INCOMING EMPLOYER SHOULD BE BOUND BY A COLLECTIVE AGREEMENT, PRE‑REFORM CERTIFIED AGREEMENT OR A STATE TRANSITIONAL INSTRUMENT
(Act, section 590, Schedule 9, and clauses 14 and 23)
Application is made for an order relating to the abovementioned *collective agreement/*pre‑reform certified agreement/*State transitional instrument in the following terms:
[Set out the terms of the order sought]
s.590
Sch 9, cl.14
Sch 9, cl.23
To the persons and organisations bound by the abovementioned agreement:
Form R59
Rule 5 of the Australian Industrial Relations Commission Rules
[or other legislation as appropriate]
APPLICATION
(no specific form provided)
Respondent/s
Provision under which application is made:
Relevant industrial instrument(s) (if any):
Order or relief sought:
Grounds upon which the applicant relies:
Form R60
Rule 65 of the Australian Industrial Relations Commission Rules
SUMMONS TO WITNESS
To [name(s), address(es) and position(s) of witness(es)]
You are summoned to attend before [name of member of the Commission] at [time] on [date] at [place] and so from day to day until the hearing of the abovementioned matter is completed or until you are excused from further attendance, to give evidence on behalf of [name of party].
This summons has been issued at the request of [ name of party who made the request]
Form R61
Rule 66 of the Australian Industrial Relations Commission Rules
ORDER FOR PRODUCTION
OF DOCUMENTS OR THINGS
To [name(s), address(es) and position(s)
You are required to produce the following documents or things before [name of member of the Commission] at [time] on [date] at [place].
(Set out documents or things required)
[Note: Instead of attending at the hearing to produce the documents or things, you may produce them to an officer of the Australian Industrial Registry at the place of the hearing not later than 4pm on the day before the day mentioned above. If it is difficult for you to get to the Commission before 4pm on that day, you should contact the Registry to make other delivery arrangements.]
This order has been issued at the request of [name of party who made the request]
Form R62
Rule 73 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN ORDER
FOR SUBSTITUTED SERVICE
Application is made for an order for substituted service for the service otherwise required by the Australian Industrial Relations Commission Rules in the above matter and that service upon the undermentioned parties be good and sufficient service and be effected by
[Set out method of service]:
[Set out names and addresses]
[Set out the grounds in numbered paragraphs, including particulars of the number of parties to the award and difficulties likely to be encountered in effecting prompt service to all those parties under the Commission’s Rules and details showing that the parties Set out above or their representatives appeared when the award was previously before the Commission.]
Note The application should be supported by a written statement in the following terms:
Note: I, [name], am the [position held], of [name of organisation, company etc] and I am authorised to act in this matter.
Form R63
Rule 80 of the Australian Industrial Relations Commission Rules
REFERRAL OF DISAGREEMENT CONCERNING MANNER OF ESTABLISHING OR VARYING A DESIGNATED WORK GROUP
Notice is given under subsection 24 (4) of the Occupational Health and Safety Act 1991 by [name of notifier] of a disagreement in the course of consultation concerning the manner of establishing or varying a designated work group.
The parties to the consultation are:
[names, addresses and contact details of parties to the consultation]
Form R64
Rule 81 of the Australian Industrial Relations Commission Rules
NOTICE OF APPEAL UNDER SECTION 48
IN the matter of: [title of matter]
Notice of an appeal under section 48 of the Occupational Health and Safety Act 1991 is given by
against a decision of
[name of investigator],
an investigator, on
to
[Insert details of decision with specific reference to the categories listed in paragraphs 48 (1) (a)‑(f) or 48 (2) (a)‑(b)].
I make the appeal as I am [Insert details of the basis on which the appellant claims the right to appeal with specific reference to the categories listed in paragraphs 48 (1) (g)‑(n) or 48 (2) (c)‑(e)].
[Set out in numbered paragraphs the grounds on which the appeal is based]
A copy of this Notice of appeal and documents lodged in accordance with subrule 76 (1) will as soon as practicable be served on the following persons:
[Insert names, addresses and contact details of persons required to be served under subrule 76(6) or (7) as the case may be]
Note If it is intended to seek an order under subsection 48 (3) of the Act that the making of the appeal affect the operation of the decision or prevent the taking of action to implement the decision, the notice of appeal must include an application to that effect, as set out below:
Note: “Application is also made for an order that the making of the appeal affect the operation of the decision or prevent the taking of action to implement the decision.”
Note: If it is intended to seek an order under subsection 48 (4) or (5) of the Act that the operation of the decision under section 47, or notice under section 29, of the Act, as the case may be, not be suspended pending determination of the appeal, the notice of appeal must include an application to that effect, as set out below:
Note: “Application is also made for an order under
Note: * subsection 48 (4) that the operation of the decision under section 47
Note: * subsection 48 (5) that the operation of a notice under section 29
Note: of the Act not be suspended pending determination of the appeal.”
Note: * Omit whichever is inapplicable.
Form R65
Rule 81 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN EXTENSION OF TIME
FOR INSTITUTING AN APPEAL
for an extension of time for instituting an appeal against a decision of
[name of investigator] an investigator,
on
to
[details of decision with specific reference to the categories listed in paragraphs 48 (1) (a)‑(f) or 48 (2) (a)‑(b)].
I make the application as I am
[Insert details of the basis on which the appellant claims the right to appeal with specific reference to the categories listed in paragraphs 48 (1) (g)‑(n) or 48 (2) (c)‑(e)].
[Set out in numbered paragraphs the grounds on which it is claimed an extension of time should be granted]
Form R66
Rule 82 of the Australian Industrial Relations Commission Rules
REFERRAL OF DISAGREEMENT CONCERNING MANNER OF ESTABLISHING OR VARYING A DESIGNATED WORK GROUP
Notice is given under subsection 12 (4) of Schedule 7 to the Petroleum (Submerged Lands) Act 1967 by [name of notifier] of a disagreement in the course of consultation concerning the manner of establishing or varying a designated work group.
The parties to the consultation are:
[names, addresses and contact details of parties to the consultation]
Form R67
Rule 83 of the Australian Industrial Relations Commission Rules
NOTICE OF APPEAL UNDER SECTION 37
OF SCHEDULE 7
IN the matter of: [title of matter]
Notice of an appeal under section 37 of Schedule 7 to the Petroleum (Submerged lands) Act 1967 is given by
against a decision of
[name of OHS inspector], an OHS inspector,
on
to [Insert details of decision with specific reference to the categories listed in paragraphs 37 (1) (a)‑(f) or 37 (2) (a)‑(b) of Schedule 7].
I make the appeal as I am
[Insert details of the basis on which the appellant claims the right to appeal with specific reference to the categories listed in paragraphs 37 (1) (g)‑(n) or 37 (2) (c)‑(e) of Schedule 7].
[Set out in numbered paragraphs the grounds on which the appeal is based]
A copy of this Notice of appeal and documents lodged in accordance with subrule 76B (1) will as soon as practicable be served on the following persons:
[Insert names, addresses and contact details of persons required to be served under subrule 76B(6) or (7) as the case may be]
Note If it is intended to seek an order under subsection 37 (3) of Schedule 7 to the Act that the making of the appeal affect the operation of the decision or prevent the taking of action to implement the decision, the notice of appeal must include an application to that effect, as set out below:
Note: “Application is also made for an order that the making of the appeal affect the operation of the decision or prevent the taking of action to implement the decision.”
Note: If it is intended to seek an order under subsection 37 (4) or (5) of Schedule 7 to the Act that the operation of the decision under section 36 of Schedule 7, or notice under section 17 of Schedule 7, to the Act, as the case may be, not be suspended pending determination of the appeal, the notice of appeal must include an application to that effect, as set out below:
Note: “Application is also made for an order under
Note: * subsection 37 (4) of Schedule 7 that the operation of the decision under section 36 of Schedule 7
Note: * subsection 37 (5) of Schedule 7 that the operation of a notice under section 17 of Schedule 7
Note: of the Act not be suspended pending determination of the appeal.”
Note: * Omit whichever is inapplicable.
Form R68
Rule 83 of the Australian Industrial Relations Commission Rules
APPLICATION FOR AN EXTENSION OF TIME
FOR INSTITUTING AN APPEAL
Application is made by [name, address and contact details of appellant]
for an extension of time for instituting an appeal against a decision of
[name of OHS inspector] an OHS inspector,
on [date of decision]
to [details of decision with specific reference to the categories listed in paragraphs 37 (1) (a)‑(f) or 37(2) (a)‑(b) of Schedule 7].
I make the application as I am [Insert details of the basis on which the appellant claims the right to appeal with specific reference to the categories listed in paragraphs 37 (1) (g)‑(n) or 37 (2) (c)‑(e) of Schedule 7].
[Set out in numbered paragraphs the grounds on which it is claimed an extension of time should be granted]
Form R69
APPLICATION BY AN ASSOCIATION OF EMPLOYERS FOR REGISTRATION AS AN ORGANISATION
We,
make application for the registration of an association of employers called
(a) that the association meets the criteria required by paragraphs 19(1) (a), (c) and (e)‑(j) inclusive of the RAO Schedule;
[Insert the rules of the association that relate to the conditions of eligibility for membership and the description of the industry (if any) in connection with which the association is proposed to be registered];
Note: *Note This application must be signed by at least 2 persons authorised to sign the application and must contain the declaration required by paragraph 21(1) (b) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003.
Form R70
APPLICATION
BY AN ASSOCIATION OF EMPLOYEES
(OTHER THAN AN ENTERPRISE ASSOCIATION) FOR REGISTRATION AS AN ORGANISATION
We,
make application for the registration of an association of employees called
(a) that the association meets the criteria required by paragraphs 19(1) (a), (b) and (d)‑(j) inclusive of the RAO Schedule;
[Insert the rules of the association that relate to the conditions of eligibility for membership and the description of the industry (if any) in connection with which the association is proposed to be registered];
Note: *Note This application must be signed by at least 2 persons authorised to sign the application and must contain the declaration required by paragraph 21(1) (b) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003.
Form R71
APPLICATION BY AN ENTERPRISE ASSOCIATION OF EMPLOYEES FOR REGISTRATION AS AN ORGANISATION
We,
make application for the registration of an association of employees called
(a) that the association meets the criteria required by section 20 of the RAO Schedule;
[Insert the rules of the association that relate to the conditions of eligibility for membership and the description of the industry (if any) in connection with which the association is proposed to be registered];
Note: *Note This application must be signed by at least 2 persons authorised to sign the application and must contain the declaration required by paragraph 21(1) (b) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003.
Form R72
Regulation 23 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
NOTICE OF OBJECTION
TO THE REGISTRATION OF AN ASSOCIATION
[insert name of association seeking registration and case number]
Notice is given of an objection to the registration of the association.
[Set out in numbered paragraphs the grounds of objection, the particulars of each ground of objection and briefly state the facts the objector relies on for each ground of objection.]
Form R73
Regulation 27 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR LEAVE TO CHANGE NAME* /AND TO ALTER RULES*
The [name of association],
which has applied for registration as an organisation, applies to the designated Presidential Member for leave to change its name*/to alter its rules*/to change its name and alter its rules* to enable it to comply with the Act*/and to remove a ground of objection taken by an objector under the Regulations*/and by the designated Presidential Member*.
Particulars of the proposed change of name*/and alterations of the rules* are as follows:
[Set out text of proposed change or alterations.]
* Omit if inapplicable.
Form R74
Paragraph 34 (1) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR CANCELLATION OF REGISTRATION
[name of organisation]
under paragraph 30(1)(a) of the RAO Schedule for the cancellation of its registration.
The full particulars of the circumstances that entitle the organisation to make the application are as follows:
[set out the full particulars]
[Signatures or Common Seal]*
* An application must be sealed with the common seal of the organisation or be signed by a person authorised to sign the application.
Note The application is to contain a declaration signed by an officer of the organisation authorised to sign the declaration verifying the facts stated in the application.
Form R75
Paragraph 34 (5) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
NOTICE OF OBJECTION TO THE CANCELLATION OF REGISTRATION OF AN ORGANISATION
[insert name of organisation seeking cancellation and case number]
Notice is given of an objection to the cancellation of registration of the organisation.
[Set out in numbered paragraphs the grounds of objection, the particulars of each ground of objection and briefly state the facts the objector relies on for each ground of objection.]
Form R76
Paragraph 35 (1) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR CANCELLATION OF REGISTRATION OF AN ORGANISATION
[insert name of organisation, person interested or Minister making application]
under paragraph 30(1)(b) of the RAO Schedule for the cancellation of the registration of the [insert name of organisation].
The full particulars of the circumstances that entitle the applicant to make the application are as follows:
[set out the full particulars]
Note The application is to contain a declaration signed by the applicant or a person authorised by the applicant verifying the facts stated in the application.
Form R77
Paragraph 36 (4) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
NOTICE OF OBJECTION TO THE CANCELLATION OF REGISTRATION OF AN ORGANISATION
[insert name of organisation subject to the application for cancellation and case number]
Notice is given of an objection to the cancellation of the organisation.
[Set out in numbered paragraphs the grounds of objection, the particulars of each ground of objection and briefly state the facts the objector relies on for each ground of objection.]
Form R78
Paragraph 60 (2) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
BALLOT PAPER CHOSEN BY ORGANISATION IN RELATION TO PROPOSED AMALGAMATION
(Name of organisation whose members are voting)
(Initials, or facsimile of initials, of the person conducting the ballot)
Record your vote on the ballot paper as follows:
if you approve the amalgamation referred to in the question set out below, place a tick (‘’) or a cross (‘’) in the space provided opposite the word ‘YES’;
if you do not approve the amalgamation referred to in the question set out below, place a tick (‘’) or a cross (‘’) in the space provided opposite the word ‘NO’.
Mark only one square.
Form R79
Paragraph 60 (2) (b) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
(Name of organisation whose members are voting)
(Initials, or facsimile of initials, of the person conducting the ballot)
Record your vote on the ballot paper as follows:
if you approve the amalgamation referred to in the question set out below, write ‘YES’ in the space provided opposite the question;
if you do not approve the amalgamation referred to in the question set out below, write ‘NO’ in the space provided opposite the question.
Form R80
Paragraph 60 (3) (a) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
BALLOT PAPER CHOSEN BY ORGANISATION AND CONTAINING AN ALTERNATIVE PROVISION IN RELATION TO PROPOSED AMALGAMATION
(Name of organisation whose members are voting)
(Initials, or facsimile of initials, of the person conducting the ballot)
This paper contains [number] ballot papers. Record your vote on each ballot paper as follows:
if you approve the amalgamation referred to in the question set out in the ballot paper, place a tick (‘’) or a cross (‘’) in the space provided opposite the word ‘YES’;
if you do not approve the amalgamation referred to in the question set out in the ballot paper, place a tick (‘’) or a cross (‘’) in the space provided opposite the word ‘NO’.
Mark only one square on each ballot paper.
Form R81
Paragraph 60 (3) (b) of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
BALLOT PAPER CONTAINING AN ALTERNATIVE PROVISION IN RELATION TO PROPOSED AMALGAMATION
(Name of organisation whose members are voting)
(Initials, or facsimile of initials, of the person conducting the ballot)
This paper contains [number] ballot papers. Record your vote on each ballot paper as follows:
if you approve the amalgamation referred to in the question set out in the ballot paper, write ‘YES’ in the space provided opposite the question;
if you do not approve the amalgamation referred to in the question set out in the ballot paper, write ‘NO’ in the space provided opposite the question.
Form R82
Regulation 121 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR CONSENT TO CHANGE THE NAME OF AN ORGANISATION
Application is made by [name of organisation] for consent to the change of the name of the organisation to:
[Set out proposed new name and the reason for the proposal]
[Signature or Common Seal]
* An application must be sealed with the common seal of the organisation or be signed by a person authorised to sign the application.
Note The application is to contain a declaration that the change or alteration was made in accordance with the rules of the organisation and stating the action taken under those rules to make the change and verifying the facts stated in the application.
Form R83
Regulation 121 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR CONSENT TO THE ALTERATION OF ELIGIBILITY RULES OF AN ORGANISATION
[name of organisation]
for consent to the alteration of the eligibility rules of the organisation to the following:
[Insert proposed rules that relate to the conditions of eligibility for membership and the description of industry (if any) in connection with which the organisation is registered as if the application had been granted and the alterations to the rules were in force, showing in distinctive characters each alteration for which consent is sought.]*
[Signature or Common Seal] **
*Each alteration for which consent is sought must be highlighted using distinctive characters. For example, deleted or replaced text may be highlighted using strikethrough formatting and new text may be highlighted using underlining or italics (provided there is no ambiguity with the formatting).
**An application must be sealed with the common seal of the organisation or be signed by a person authorised to sign the application.
Note The application should also set out, in sufficient particularity to allow the proposal to be properly considered, the following:
Note: 1. the particulars of the proposed alteration;
Note: 2. the reason for the proposed alteration;
Note: 3. the effect of the proposed alteration;
Note: and contain a declaration that the alteration was made in accordance with the rules of the organisation and stating the action taken under those rules to make the alteration and verifying the facts stated in the application.
Form R84
Regulation 128 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR CERTIFICATE UNDER SECTION 180 OF THE RAO SCHEDULE
I,
[full name] of [private address]
(Telephone Nos: Business Home ),
apply under section 180 of the RAO Schedule, for a certificate to the effect that my conscientious beliefs do not allow me to be a member of an association of a kind described in paragraph 18(a) or 18(b) of the RAO Schedule.
My occupation is
The name and address of my business/employer* is
The grounds on which my application is made are as follows:
I attach a statutory declaration verifying the information stated in this application.
Form R85
Regulation 129 of the Workplace Relations (Registration and Accountability of Organisations) Regulations 2003
APPLICATION FOR RENEWAL OF CERTIFICATE UNDER SECTION 180 OF THE RAO SCHEDULE
I,
[full name]
of [private address]
(Telephone Nos: Business Home ),
apply under section 180 of the RAO Schedule, to renew a certificate to the effect that my conscientious beliefs do not allow me to be a member of an association of a kind described in paragraph 18(a) or 18(b) of the RAO Schedule.
My occupation is
The name and address of my business/employer* is
The grounds on which my application is made are as follows:
I attach a statutory declaration verifying the information stated in this application.
Notes to the Australian Industrial Relations Commission Rules 2007
Note 1
Note: The Australian Industrial Relations Commission Rules 2007 (in force under the Workplace Relations Act 1996) as shown in this compilation comprise Select Legislative Instrument 2007 No. 1 amended as indicated in the Tables below.
Note: > Note: Table of Instruments
Year andNumber
Date of FRLI registration
Date ofcommencement
Application, saving ortransitional provisions
2007 No. 1
15 Jan 2007 (see F2007L00117)
16 Jan 2007
2008 No. 73
14 May 2008 (see F2008L01394)
15 May 2008
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Note: > Note: Table of Amendments
Schedule Sch 1 - Australian Industrial Relations Commission Rules 2007 - Forms | Zoe