Industrial Relations Act 1984
application for hearing in respect of an industrial dispute - 
section 29(1A)

The President, 
Tasmanian Industrial Commission
GPO Box 1108
HOBART    Tas    7001	IMPORTANT NOTE FOR APPLICANTS
An application for a hearing before a Commissioner in respect of an industrial dispute relating to termination of employment or severance pay relating to redundancy is to be made within 21 days after the date of termination.  However, the applicant has the opportunity at the hearing to present reasons why exceptional circumstances prevented the application being made within the time limit.	

The details of my application are:
Part A.	Applicant’s Personal Particulars
1.	What is your full name?

2.	What is your address?

3.	What is your email address?

4.	What is your telephone number –	at home? 

	at work? 

	mobile? 
5.	Are you a former employee of the employer mentioned in Part D below?

	Yes	No
Part B.	Purpose of Application for a Hearing
1.	Does your dispute with the former employer relate to any one or more of the following?–
•	a dispute in relation to termination of employment–section 29(1A)(a)

	Yes	No

•	severance pay in respect of termination of employment as a result of redundancy–section 29(1A)(b)	Yes	No
•	alleged breach of an award or a registered agreement–section 29(1A)(c)

	Yes	No

•	a dispute over the entitlement to long service leave, or payment instead of any such leave, or the rate of ordinary pay at which any such leave or payment is to be paid–section 29(1A)(d) 	Yes	No

Part C.	Representation
1.	Will you be represented at the hearing by an agent, e.g. union, solicitor, consultant, etc?

	Yes	No
2.	If the answer to question 1. above is “Yes”, please identify the agent and provide full particulars of the agent’s address and telephone number.

3.	Do you want the Commission to serve notices, etc regarding the hearing on you personally or on your agent? Please indicate your choice.	Me	My agent
Part D.	Particulars of Former Employer
1.	Who was your former employer? Please provide the correct and full name of the company or business for which you worked. (Your pay slip or income tax group certificate may help you). Please be as accurate as you can with your answer to this question

2.	What is the employer’s telephone number and, if known, email address?

Telephone:		Email:			Email:
3.	What is the street address of your former employer’s place of business?

Part E.	Particulars of Employment with Former Employer

1.	On what date did you commence working for your former employer?

2.	On what date did you cease working for your former employer?

3.	For how many hours per week were you usually employed?

4.	What was your rate of pay or annual salary?
5.	What was your employment status, i.e. full-time, part-time, casual, intermittent, piece work, trainee, probationary or other? 

6.	Please briefly describe the work your former employer required you to perform.

	7.	What was your work classification or job title?

Part F.	Particulars of Award or Registered Agreement Coverage
1.	What is the title of the industrial award or registered agreement under which you were employed?

2.	Is the award or agreement registered in the Tasmanian Industrial Commission or in the Fair Work Commission? (Please specify which Commission)

3.	If you were not employed under an award or registered agreement, please provide details of your contract of employment.

Part G.	Additional particulars regarding Termination of Employment - s.29(1A)(a)
Please explain the facts and circumstances that give rise to your application.

If insufficient room, please provide an attachment

Part H.	Additional particulars regarding claims for Severance Pay where Termination of Employment is the result of Redundancy - s.29(1A)(b)
1. 	What are the details of your claim for severance pay?

If insufficient room, please provide an attachment

Part I.	Additional particulars regarding claims for alleged Breach of Award or Registered Agreement - s.29(1A)(c)
1.	Please specify the award or registered agreement provision(s) that you allege your former employer breached.

2.	Please provide full details of each award or registered agreement breach that you allege has occurred, including relevant dates and money amounts or other award benefits that you claim.

If insufficient room, please provide an attachment
Part J	Additional particulars regarding claims for a dispute over the entitlement to long service leave, or payment instead of any such leave, or the rate of ordinary pay at which any such leave or payment is to be paid – s.29(1A)(d)

If insufficient room, please provide an attachment

Signature…………………………………………………………………….Date: …………………………………………