QUEENSLANDINDUSTRIALRELATIONSCOMMISSION

NUMBER: AD/

Form83 -Applicationforexemptionorrenewalofexemption
Anti-Discrimination Act 1991, section 113

Industrial Relations (Tribunals) Rules 2011, rule 80A

Version3

Applicant:(NAMEOFAPPLICANT INMATTER)

ThisisanApplicationtotheQueenslandIndustrialRelationsCommission,pursuantto

section 113 of the Anti-Discrimination Act 1991

1.TheApplicant:

Name
Company / ABN
Postal address
Suburb/Town / Postcode
Phone number / Faxnumber
Mobile number
Emailaddress

(a)Doesthe Applicant have a representative?

Arepresentativemightbealawyer,aunion,anagentorafamilymemberorfriendwho will speak on behalfoftheApplicant. Thereis norequirement to havea representative.

☐Yes-Providerepresentative’sdetails belowandfileaForm33or34 ☐No

b)The Applicant’s representative

Organisation
Name ofcontactperson
Postaladdress
Suburb/Town / Postcode
Phone number / Faxnumber
Mobile number
Emailaddress

2.DETAILS OFEXEMPTION SOUGHT:

(a)Provision of Act from which exemption is sought:

(b)Period or further period for which the exemption is sought:

(c)Person, people or class of people for whom the exemption is sought:

3.MATERIAL FACTS RELIED ON TO SUPPORT THE APPLICATION

(State concisely and in consecutively numbered paragraphs the material facts relied on to support the application and any other matters required under R.80A.)

Further, I [make oath and say] [solemnly and sincerely affirm and declare]

All the facts and circumstances deposed to in this my affidavit are within my own knowledge and belief, except for the facts and circumstances deposed to from information only, and my means of knowledge and sources of information appear on the face of this my affidavit.

5.Signature

Signature
Name
Date

Taken by:

Sworn/Affirmed by the deponent at:
on:
Signature
Print Name
Date
Justice of the peace/commissioner for declarations/lawyer/other qualified person

Statement made on behalf of the applicant:

Usingnumbered paragraphs, pleaseset out detailed information in support of the application