File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

CIVIL DISPUTE APPLICATION 
		
	*s16 ACT Civil and Administrative Tribunal Act 2008		

APPLICANT’S DETAILS	
Name	 
	
Address line 1	
 	
Address line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
If a corporation:

ACN/ABN

Address of registered officer/public officer		
		
APPLICANT’S REPRESENTATIVES DETAILS (IF ANY)	
Name

Address line 1	
 	
Address line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
RESPONDENT’S DETAILS	
 Name		
Address line 1		
Address line 2		
If a corporation:

ACN/ABN

Address of registered officer/public officer		
		
Telephone	                                                                    Fax:                                       
Email:	

Grounds of application (set out briefly the grounds of the application)	

	

	

	

	

	

	

	

	

	

	

Previous attempts to resolve the dispute 	
*The applicant and the respondent have attempted to resolve their dispute in the following way:	

	

	

	

	
	
*The applicant and respondent have made no prior attempts to resolve their disputes	
Remedy sought (Please describe here the details of any orders you are seeking and also the details of any amounts that you are seeking for compensation).	

	

	

	

	
Amount	Reason claimed	

		
		
	TOTAL AMOUNT OF APPLICATION	

Applicant’s signature			Date