South Australian Employment Tribunal
Form 53 – Application to revoke or dispute WHS Permit (Work Health and Safety)
Form 53
Application to revoke or dispute WHS Permit (Work Health and Safety)
Case Number(SAET use only)
About this form
- This is an application that SAET revoke a WHS entry permit, or deal with a dispute about the exercise of right of entry under the Work Health and Safety Act 2012 (SA).
- A copy of this application is to be provided by the applicant to the other parties considered to have a direct interest in the matter (or their representatives) as nominated within this form.
- Submitting an incomplete form (including any relevant supporting documents) may result in delays.
The Application
The applicant applies to SAET pursuant to the Work Health and Safety Act 2012 seeking SAET to:
☐ revoke a WHS entry permit (section 138)
☐ deal with a dispute about the exercise or purported exercise by a WHS entry permit holder of a right of entry under the WHS Act (section 142)
☐ deal with a dispute about whether a request about entry is reasonable (section 128)
Party details
Applicant
The applicant is / ☐ a WHS permit holder ☐ an employer ☐ Other - (specify):Organisation name (if relevant)
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Do you require an interpreter? / ☐ No ☐ Yes. Please specify language:
Do you haver any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:
Is anyone representing you? / ☐ No ☐ Yes. Please specify:
Representative detail (if required)
OrganisationContact First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
WHS Entry Permit holder
Same as applicant? / ☐ No ☐ Yes - move to next sectionTitle / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Employer
Same as applicant? / ☐ No ☐ Yes - move to next sectionTitle / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Other party 1 - provide details of other parties that have a direct interest in the matter
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Other party 2 - provide details of other parties that have a direct interest in the matter
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):First name / Last name
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Details of application
Orders sought
Describe the following in the space provided below:
- The general circumstances in which the matter has arisen including the location of the workplace;
- The applicant’s claim in relation to the matter(s) in dispute;
- The steps already taken to attempt to resolve the matter; and
Attach additional pages if necessary.
LODGING YOUR COMPLETED FORM
The person lodging this form must send a copy to all other party/ies.
Name of person lodgingSignature
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
SAET Registry: 08 8207 0999