File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR ENDORSEMENT 

APPLICATION FOR ENDORSEMENT

The Tribunal will consider the information provided in this application and any documentation attached and may make an order within 2 days of lodgement.  If the Tribunal requires further information the contact officer nominated in the application will be contacted.  Whilst an appearance before the Tribunal may not be necessary, if you are required to appear before the Tribunal every effort will be made to hear the matter as soon as possible.

FURTHER ENQUIRIES MAY BE DIRECTED TO THE TRIBUNAL 

A. 	LESSOR  DETAILS

Name:	
	
Address:	

	
Contact officer or agent:	
	
Telephone Contact:	
	
Facsimile Contact: 	
	
E-MAIL Address	

TENANT  DETAILS

Name:	
	
Address:	

	
Contact officer or agent:	

Telephone Contact:	………………………………………………………………………...	
Facsimile Contact: 	
	
E-MAIL Address	

DETAILS RELATING TO REPRESENTATION OR APPEARANCE BEFORE THE TRIBUNAL

    The lessor will be represented by the contact officer/agent nominated in this 
       application; or
•	 The lessor will be represented before the Tribunal (if necessary) by:

Who can be contacted at:
Address:                     

Telephone Contact:    

Facsimile Contact:     

EMAIL Address:       

Times available:                  

	

•	The tenant will be represented by the contact officer / agent nominated in this application; or 
•	The tenant will be represented before the Tribunal (if necessary) by:

Who can be contacted at:
Address:                      

Telephone Contact:     

Facsimile Contact:      
.
EMAIL Address:        

Times available:                      

	

D. 	DETAILS OF THE AGREEMENT

A copy of the agreement between the lessor and the tenant should also be attached to this application.
Date agreement signed:  ……/……/……
Date upon which the tenant commences occupancy of the premises: ……/……/……	

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E.	DETAILS OF THE INCONSISTENT TERMS.

Please identify:
(a)	clauses of the prescribed terms which are effected by the inconsistent terms
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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….  and
(b)	clauses of the agreement which are inconsistent with the prescribed terms …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………	

F.	DETAILS OF THE CIRCUMSTANCES RELATING TO THE AGREEMENT

Please provide details of the circumstances relating to:
(a)	the consent of the lessor and the tenant to the inconsistent term/s proposed;
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
(b)	the nature and substance of any negotiations between the lessor and the tenant
      relating to the inconsistent term/s proposed;
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
(c)	whether the inclusion of the term would result in any material detriment to either the lessor or the tenant;
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………and

(d)	
whether a term in substantially the same form (if known) has been endorsed before.
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DATED this……………..day of……………………………..20……

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                                   (signature of lessor)

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                                  (signature of tenant)