Part Form 1—Ballot paper under Part 3 of Chap - Fair Work Regulations 2009 - Form 1—Ballot paper under Part 3 of Chapter 3

Form 1—Ballot paper under Part 3 of ChapForm 1—Ballot paper under Part 3 of Chapter 3

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Form 1—Ballot paper under Part 3 of Chapter 3

(regulation 3.16)

Fair Work Act 2009, Chapter 3, Part 3.3, Division 8

BALLOT OF MEMBERS OF(Name of organisation)BALLOT PAPER IN RESPECT OFPROTECTED ACTION BALLOTCLOSING DATE OF BALLOT: (Date)	(Initials, or facsimile of initials, of the person conducting the ballot)

The proposed protected industrial action to which this ballot applies is [description].

DIRECTIONS TO VOTERS

Record your vote on the ballot paper as follows:

 if you approve the proposed protected industrial action, mark the YES box opposite the question;

 if you do not approve the proposed protected industrial action, mark the NO box opposite the question.

Do not place on this paper any mark or writing that may identify you.

QUESTION(S) FOR VOTERS

<table cellspacing="0" cellpadding="0" style="width:100%; border-collapse:collapse"><tbody><tr style="height:29pt"><td rowspan="3" style="width:73.1%; padding-right:4pt; padding-left:4pt; vertical-align:top"><p style="margin-top:24pt; margin-right:5.4pt; margin-left:5.95pt; text-align:center"><span style="font-size:9pt">(Text of question or questions</span></p><p class="Tabletext" style="text-align:center"><span style="font-size:9pt">as ordered by Fair Work Commission)</span></p></td><td style="width:18.98%; border-right:0.75pt solid #000000; padding-right:3.62pt; padding-left:4pt; vertical-align:top"><p style="margin-top:9pt; text-align:center"><span style="font-weight:bold">YES</span></p></td><td style="width:7.92%; border:0.75pt solid #000000; padding-right:3.62pt; padding-left:3.62pt; vertical-align:top"><p><span></span></p></td></tr><tr style="height:29pt"><td style="width:18.98%; padding-right:4pt; padding-left:4pt; vertical-align:top"><p><span></span></p></td><td style="width:7.92%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:4pt; padding-left:4pt; vertical-align:top"><p><span></span></p></td></tr><tr style="height:29pt"><td style="width:18.98%; border-right:0.75pt solid #000000; padding-right:3.62pt; padding-left:4pt; vertical-align:top"><p style="margin-top:9pt; text-align:center"><span style="font-weight:bold">NO</span></p></td><td style="width:7.92%; border:0.75pt solid #000000; padding-right:3.62pt; padding-left:3.62pt; vertical-align:top"><p><span></span></p></td></tr></tbody></table>

INFORMATION FOR VOTERS

The applicant(s) for the protected action ballot order is or are [name(s)]. 1