File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR THE ENDORSEMENT OF THE TERM/S OF A RESIDENTIAL TENANCIES AGREEMENT PREVIOUSLY ENDORSED BY THE TRIBUNAL

The lessor:		

							and

The tenant/s		

jointly apply for the endorsement of a term/s of the attached residential tenancy agreement that are inconsistent with the prescribed terms.  (NOTE:  The residential tenancy agreement must be filed with this application.)

The Tribunal endorsed the terms of an agreement in identical terms to the attached agreement on the               day of                                , 20………  .  In the matter of RE           of 20…..

The lessor and the tenant/s each declare that the inclusion of the term/s of the residential tenancy agreement that are inconsistent with the prescribed term/s was not obtained by fraud or undue influence.

FURTHER ENQUIRIES MAY BE DIRECTED TO THE TRIBUNAL ON TELEPHONE 62071740 OR FACSIMILE 62054855.

THIS APPLICATION MAY BE LODGED BY FACSIMILE.  NO FEES ARE PAYABLE.

	Lessor	Tenant	
Contact Officer:	__________________________	__________________________	
Telephone Contact:	__________________________	__________________________	
Facsimile Contact:	__________________________	__________________________	
Email Address:	__________________________	__________________________	

Signed for and on behalf of the lessor by:	Signed by the tenant/s:         	
		
_____________________…../.…/….	                       _____________________…../…./.…	
                                             (Date)	                                                                     (Date 
(name of tenant)__________________________	
(name and position within lessor organisation)

______________________________	

                       _____________________…../…./….
                                                                     (Date)	
______________________________	(name of tenant)__________________________