File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL
LATE APPLICATION FOR DISCRIMINATION COMPLAINT TO BE HEARD*

	* under s53B Human Rights Commission Act 2005		

APPLICANT/COMPLAINANT 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:	
RESPONDENT’S DETAILS/PERSON COMPLAINED ABOUT 	
Name

Address line 1	
 	
Address line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
Type of statement given (Indicate if it was a discrimination referral statement or a statement in a final report. Attach a copy of the statement)	
	
Date you were given statement		

Circumstances relied on (State what exceptional circumstances prevented you from requiring your complaint to be referred to the Tribunal within 60 days)

	

	
Applicant’s signature		Date