Protection Orders Act 2001—Form 4
(see s 13)
Application for amendment or revocation of order

Australian Capital Territory

I (applicants name)
now apply to have magistrates court order (order number)	revoked/varied as follows:

[Signature]	
Applicant	

NOTE:	This application is set down for hearing on the 	day of		
20 	at 	am/pm at the Magistrates Court at	
Dated this 	day of		20	.

[Signature]
Registrar

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