Protection Orders Act 2001—Form 3
(see s 11(1))
Application for personal protection order (in relation to a workplace)

Australian Capital Territory

I (name of applicant)
being an aggrieved person/representative of an aggrieved person/police officer, apply for orders against (name of Respondent)
as set out in this application.

I believe the Respondent has: 	(State briefly and concisely the facts relied upon)
(a)	Caused personal injury or threatens to cause personal injury to an employee in the employee’s capacity as an employee at the workplace in that;
(b)	Caused damage to property, or threatens to cause damage to property, in the workplace in a way that causes reasonable fear in an employee in that:
(c)	Engaged in conduct of an offensive or harassing nature in that:
and unless the Respondent is restrained I believed that such conduct is likely to happen again.

The Applicant seeks orders for a period of	(specify period not exceeding 24 months)	in the terms outlined in this form.
An interim order is sought in this matter (or) is not sought at present.

The orders sought by the applicant are that the respondent be prohibited from:
(a)	entering the workplace;
(b)	being within a particular distance from the workplace;
(c)	contacting, harassing, threatening or intimidating an employee at the workplace;
(d)	damaging property in the workplace;
(e)	causing someone else to do something mentioned in paragraph (c) or (d);

Dated this 	day of 		20	[Signature]
Applicant/Representative

Endnote
1	Under the Court Procedures Act 2004 A2004-59, pt 8, this form became a form approved under that Act.

©  Australian Capital Territory 2005