File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR REVIEW
OF A DECISION

			

APPLICANT’S DETAILS	
Name

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	
Title of Department or Agency that made decision 		
DETAILS OF THE DECISION 	
Date decision made:                                                Date you received decision:	
What is the decision (briefly describe the decision and attach a copy)

	

	

	

Why the decision should be reviewed (It is important that you tell us your reasons for appealing and why you think the decision is wrong. Please use an attachment if there is insufficient space).	

	

	

	

	

	

	

	

	
Application for extension of time to lodge the application for review  - You must complete this section if your application is late. Normally only 28 days are allowed between the date you received notice of the decision and the date you lodge this application.
Why your application is out of time and why you want an extension of time (Please use an attachment if insufficient space).

	

Applicant’s Signature			Date