South Australian Employment Tribunal

Form A45 – Notification of an industrial dispute or grievance

Form A45

Notification of an industrial dispute or grievance

Case Number
(SAET use only)

About this form

  • This form is used to:

–notify SAET of an industrial dispute under Chapter 5, Part 3, Division 3, of the Fair Work Act 1994; or

–apply to SAET for remedy concerning a claim arising out of a genuine industrial grievance where there is no other impartial grievance resolution process reasonably available (section 17 of the Fair Work Act 1994).

  • A party who orally seeks the assistance of SAET shall provide the details set out in this form and must then lodge the form with SAET within 2 business days.
  • Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Party details

Applicant

Organisation (if relevant)
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Do you require an interpreter? / ☐ No ☐ Yes. Please specify language:
Do you have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Respondent / other party A

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Respondent / other party B

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Respondent / other party C

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Details of the Dispute

Award or Agreement or other industrial instrument covering employment (if known) / What type of Award or Agreement covers the employment?
 State  Federal  None
Name of Award, Agreement or other industrial instrument (if applicable):
12. Summary of Matters in Dispute or Aggrieved, Including any Industrial Action Taken or Threatened (attach additional pages if necessary)
13.What assistance is sought from SAET? / Tick all relevant boxes
 Conciliation
 Mediation
 Arbitration
 Other:

LODGING YOUR COMPLETED FORM

The person lodging this form must send a copy to all other party/ies.

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

SAET Registry: 08 8207 0999