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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR APPEAL
FROM AN ACAT DECISION

			

FULL NAME/COMPANY NAME:_______________________________________________________________

TELEPHONE: _______________________TELEPHONE:___________________	FAX: ____________________
                                       (Business)				       (Home)

EMAIL ADDRESS: ___________________________________________________________________________

POSTAL ADDRESS:  ___________________________________________________________________________________

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REPRESENTATIVE’S NAME AND ADDRESS: (If you have one) 

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TELEPHONE: ___________________FAX: ________________

EMAIL: ____________________________________

ACAT REFERENCE NUMBER: ______________________________________________________________________

DATE OF THE DECISION:_______________________DATE YOU RECEIVED DECISION:___________________

REASONS FOR APPEAL – PLEASE STATE: (1) THE NATURE OF THE CASE, (2) ANY QUESTIONS OF LAW OR FACT INVOLVED, (3) ANY ADDITIONAL EVIDENCE YOU WISH TO INTRODUCE, (4) REASONS WHY THE APPEAL SHOULD PROCEED, (5) WHAT REMEDY YOU ARE SEEKING 

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 (You may attach additional information/documents/statements)

DO YOU WISH THE MATTER TO BE REFERRED DIRECTLY TO THE SUPREME COURT: YES / NO

SIGNATURE: __________________________________	DATE: ______________________________________