File Number

            /
	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION TO VARY AN ORDER

		
		
Applicant

Respondent

RE:  PREMISES AT :		

THE  APPLICANT/RESPONDENT APPLIES FOR THE FOLLOWING ORDERS OR DIRECTIONS:

1	That the Order of the Tribunal made on  be varied in the following manner

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

THE GROUNDS FOR MAKING THIS APPLICATION ARE AS FOLLOWS:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

DATE:  __________/___________/_____________			
                          
                             ____________________________________________________	
                                   [signed] APPLICANT/RESPONDENT		

This application has been set down for determination by the Tribunal on Level 4, ACT Health Building, 1 Moore Street Canberra City on 

The_____________________ day of ______________________ 20_________

at _____________________________ O’clock in the forenoon/afternoon, or so soon thereafter as the course of business permits.

		__________________________________________________						[signed]  DEPUTY REGISTRAR

								______________________
									(date)