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
Email
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)

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

WHS Entry Permit holder

Same as applicant? / ☐ No ☐ Yes - move to next section
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Employer

Same as applicant? / ☐ No ☐ Yes - move to next section
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
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
Email
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
Email
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 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