Form 4—Affected member certificateForm 4—Affected member certificate

## Form 4—Affected member certificate (regulation 3.29) Fair Work Regulations 2009, regulation 3.29 AFFECTED MEMBER CERTIFICATE This certificate is issued to \[name of organisation\]. Section 520 of the Fair Work Act 2009 authorises the Fair Work Commission to issue an affected member certificate if a permit holder seeks to enter premises for the purpose of investigating contraventions, or suspected contraventions, of the Fair Work Act 2009, or a term of a fair work instrument. For section 520 of the Fair Work Act 2009, the Fair Work Commission is satisfied that: - a member of the organisation performs work on the premises below; and - the organisation is entitled to represent the industrial interests of the member; and - a suspected contravention of the Fair Work Act 2009, or a term of a fair work instrument, relates to, or affects, that member. For this certificate: (a) The premises to which it relates are: \[name and address of premises\] (b) The suspected contravention or contraventions to which it relates are: \[particulars of suspected contravention or contraventions\] Dated 20 Delegate of the Fair Work Commission Schedule 3.4—Forms for certain dismissals (regulation 3.30)