File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL
APPLICATION TO
REVIEW OR APPEAL DECISION  ABOUT OCCUPATIONAL LICENSING OR DISCIPLINARY ACTION*

	*for applications under authorising laws noted on attachment		

APPLICANT’S DETAILS	
Name	 	
Type of Licence Sought or No. of Licence Held where relevant	 	
Address Line 1	
 	
Address Line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
APPLICANT’S REPRESENTATIVES DETAILS (IF ANY)	
Name

Address Line 1	
 	
Address Line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
DECISION MAKER’S DETAILS	
Name	 	
Address Line 1	
 	
Telephone	                                                                    Fax:                                       
Email:	
What decision do you want to appeal or have reviewed (attach a copy of the decision)	

	
	
Date Decision Made                                                     Date You Received Decision

Law under which your application is brought (a list of authorising laws is attached)

	

Reasons for applying for review (use an attachment if insufficient space. Further details can also be provided in an accompanying affidavit or  statement)	

	

	

	

	

	

	

	
	
Applicant’s signature		Date		

INFORMATION ABOUT APPLICATIONS TO REVIEW DECISIONS ABOUT DISCIPLINARY ACTION

This Application form should be used for applications to the ACT Civil and Administrative Tribunal (the ACAT) to review a decision to refuse to give or renew a licence or about some other disciplinary action. It can also be used to appeal a decision to dismiss a complaint where authorised under the following laws:

Health Professionals Act 2004
Legal Profession Act 2006                                            
Security Industry Act 2003 
Agents Act 2003
Consumer Credit (Administration) Act 1996
Sale of Motor Vehicles Act 1977
Tobacco Act 1927
Architects Act 2004
Surveyors Act 2007
Construction Occupations (Licensing) Act 2004
Liquor Act 1975

A copy of the relevant decision should be attached to the application. The applicant should also lodge an affidavit or a statement setting out the reasons for challenging the decision in detail if the application form does not have enough space. The affidavit or statement should attach copies of documents that further explain the basis for the application and/or upon which the applicant seeks to rely. 

Applications brought under the Security Industry Act 2003 and the Agents Act 2003 should be lodged in person between the hours of 9am and 4.30pm Monday to Friday at the office of the ACAT at  Level 2, 12 Moore Street in Canberra or by mail to GPO Box 158, Canberra ACT  2601 or by fax to (02) 6207 7739

Other applications should be lodged in person between the hours of 9am and 4.30pm at the ACAT, ACT Magistrates Court Building, Knowles Place, Canberra City or by mail to GPO Box 370, Canberra ACT 2601 or by fax to (02) 6205 4855