Western Australian Consolidated Regulations

INDUSTRIAL RELATIONS COMMISSION REGULATIONS 2005 - SCHEDULE 1

Form 1 — Notice of application (general)

[r. 13, 27(3), 58, 59(1), 73(1) and (2), 82(8), 102(7), 103(9) and 104(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..................................			of 20........................
Notice of application
To:	.................................................................................................................................
	.................................................................................................................................
	(name, address and telephone number of respondent/s — attach schedule if necessary)
TAKE NOTICE THAT			...........................................................................................
			...........................................................................................
(name, address and telephone number of applicant/s — attach schedule if necessary)
has this day applied to the				........................................................................................
				Commission / Public Service Arbitrator / Public Service Appeal Board / Railways Classification Board
For:	.................................................................................................................................
(examples: an order / a conference / registration of a new agreement / issuance of a new award)
The grounds on which the application is made are:
.............................................................................................................................................
.............................................................................................................................................
(give details or attach schedule if necessary)
				...................................................................
				...................................................................
				(signature of applicant/s)
NOTE:         It is important to correctly state the full name of the employer. If the employer in this matter is a trading, financial or foreign corporation the Commission may not have jurisdiction to deal with the matter. If known, please indicate whether the employer is one of the following:
ο Company         ο Incorporated association         ο Trust         ο Unincorporated (e.g. sole trader, partnership or other)         ο State government agency         ο Other ...............................
This notice must be completed by the applicant, signed and, where necessary, sealed, and a written statement of claim or other adequate description of the subject matter of the application must be attached. For endorsements, see the back of this Form. Where a fee is payable with an application it must be paid at the time of lodgment of the application, or within 7 days of the lodgment, or the application will not be processed. (Stamp of Commission)

        [Form 1 amended in Gazette 10 Jul 2009 p. 2741.]

Form 2 — Notice of application (s. 29(1)(b)(i))

[r. 61(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..................................			of 20........................
Notice of application
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of employer — attach schedule if necessary)
NOTE:         It is important to correctly state the full name of the employer. If the employer in this matter is a trading, financial or foreign corporation the Commission may not have jurisdiction to deal with the matter. If known, please indicate whether the employer is one of the following:         ο Company         ο Incorporated association         ο Trust         ο Unincorporated (e.g. sole trader, partnership or other)         ο State government agency         ο Other ............................
TAKE NOTICE THAT			..........................................................................................
			..........................................................................................
(name, address and telephone number of applicant — attach schedule if necessary)
has this day applied to the Commission for an order of reinstatement or compensation in respect of a harsh, oppressive or unfair dismissal for the reasons set out in the attached statement.
.............................................................................................................................................
.............................................................................................................................................
				...................................................................
				(signature of applicant)
This notice must be completed by the applicant, signed and, where necessary, sealed, and a written statement of claim or other adequate description of the subject matter of the application must be attached. For endorsements, see the back of this Form. Where a fee is payable with an application it must be paid at the time of lodgment of the application, or within 7 days of the lodgment, or the application will not be processed. (Stamp of Commission)

        [Form 2 amended in Gazette 10 Jul 2009 p. 2741.]

Form 3 — Notice of application (s. 29(1)(b)(ii))

[r. 61(2)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..................................			of 20........................
Notice of application
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of employer — attach schedule if necessary)
TAKE NOTICE THAT			..............................................................................................
			..............................................................................................
(name, address and telephone number of applicant — attach schedule if necessary)
has this day applied to the Commission for an order in respect of his or her claim that he or she has not been allowed by you a benefit, not being a benefit under an award or order, to which he or she is entitled under his or her contract of employment for the reasons set out in the attached statement.
.............................................................................................................................................
.............................................................................................................................................
				...................................................................
				...................................................................
				(signature of applicant/s)
This notice must be completed by the applicant, signed and, where necessary, sealed, and a written statement of claim or other adequate description of the subject matter of the application must be attached. For endorsements, see the back of this Form. Where a fee is payable with an application it must be paid at the time of lodgment of the application, or within 7 days of the lodgment, or the application will not be processed. (Stamp of Commission)

        [Form 3 amended in Gazette 28 Apr 2006 p. 1652; 10 Jul 2009 p. 2742.]

Form 4 — Statutory declaration of service

[r. 28(1), 98(4) and (5), 99]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
				No. ..................................					of 20....................
IN THE MATTER OF a claim concerning				..............................................................................
				(state nature of proceedings)
Statutory declaration of service
I,	...................................................................................................................................
	(full name in block letters)
in the State of Western Australia					...........................................................................
					(occupation)
sincerely declare that on the								......................................................
								(date)
I did serve		.....................................................................................................................
		(description of document served)
upon		.....................................................................................................................
		(name of person or party served)
by		.....................................................................................................................
		(state method of service)
at		.....................................................................................................................
(city, town or suburb where service occurred, or in case of service by post, address of person or party served)
This declaration is true and I know that it is an offence to make a declaration knowing that it is false in a material particular. This declaration is made under the Oaths, Affidavits and Statutory Declarations Act 2005 .
Declared at		...............................................					in the State of Western Australia,
(city, town or suburb where declaration made)
this		............................	day of			...........................................				20 ..............
before me		.............................................				...................................................................
(signature of authorised witness)						(signature of person making the declaration)
.....................................................................
(authority of witness)
(Stamp of Commission)

        [Form 4 amended in Gazette 28 Apr 2006 p. 1652‑3; 22 Jan 2008 p. 194.]

Form 5 — Notice of answer and counter‑proposal

[r. 14, 48(5), 50(6) and 61(4)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. .................................			of 20........................
Notice of answer and counter-proposal
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of applicant/s — attach schedule if necessary)
TAKE NOTICE THAT			...........................................................................................
			...........................................................................................
(name, address and telephone number of respondent/s — attach schedule if necessary)
has this day filed a statement in answer to the claims made by you in the above number matter.
The particulars to the answer and counter-proposal are:
.............................................................................................................................................
.............................................................................................................................................
				..............................................................................
				..............................................................................
				(signature of respondent/s)
NOTE:         It is important to correctly state the full name of the employer. If the employer in this matter is a trading, financial or foreign corporation the Commission may not have jurisdiction to deal with the matter. If known, please indicate whether the employer is one of the following:         ο Company         ο Incorporated association         ο Trust         ο Unincorporated (e.g. sole trader, partnership or other)         ο State government agency         ο Other .............................
This notice must be completed by the respondent/s, signed and, where necessary, sealed and a written statement admitting or disputing each claim made by the applicant/s must be attached. (Stamp of Commission)

        [Form 5 amended in Gazette 10 Jul 2009 p. 2742.]

Form 6 — Notice of retirement from agreement

[r. 56(a)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. .................................		of 20........................
Notice of retirement from agreement
To:	...................................................................................................................................
	...................................................................................................................................
	(name, address and telephone number of party/parties to whom notice is directed)
TAKE NOTICE THAT		..............................................................................................
		..............................................................................................
		(name, address and telephone number of party giving notice)
being a party to registered industrial agreement number ............................................... of 20 ............................. has this day given notice of intention to retire from and cease to be a party to the said agreement at the expiration of 30 days from the date of this notice.
				.......................................................................
				(signature of party giving notice)
This notice signifying intention to retire from an industrial agreement must be completed by the person giving such notice, signed and where necessary sealed by him or her, filed in the office of the Registrar and, as soon as practicable after the notice is filed, be served by the party retiring, on each other party to the agreement. (Stamp of Commission)

        [Form 6 amended in Gazette 10 Jul 2009 p. 2742.]

Form 7 — Notice of referral to the Occupational Safety and Health Tribunal

[r. 96(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission sitting as the Occupational Safety and Health Tribunal
		No. OSHT.....................		of 20........................
Notice of referral to the Occupational Safety and Health Tribunal
TAKE NOTICE THAT	.........................................................................................
	.........................................................................................
(name, address and telephone number of applicant — attach schedule if necessary)
has this day referred to the Tribunal:
.............................................................................................................................................
.............................................................................................................................................
(state nature of matter e.g. review, appeal, claim)
The grounds on which the referral is made are —
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
(give details — attach schedule if necessary)
			..........................................................................
			(signature/seal of applicant or signature of applicant’s solicitor or agent)
(Stamp of Commission)
For endorsements see the back of this form or the attachment(s).

        [Form 7 amended in Gazette 10 Jul 2009 p. 2742.]

Form 7A — Notice of referral to the Road Freight Transport Industry Tribunal

[r. 99B]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission sitting as the Road Freight Transport Industry Tribunal
		No. RFT .......................		of 20........................
Notice of referral to the Road Freight Transport Industry Tribunal
TAKE NOTICE THAT	..........................................................................................
	..........................................................................................
(state name, address and telephone number of applicant — the categories of persons who may refer a dispute or matter are set out in the Owner‑Drivers (Contracts and Disputes) Act 2007 section 40)
has this day referred to the Tribunal —
.............................................................................................................................................
.............................................................................................................................................
(state nature of dispute or matter and identify whether the dispute or matter arises under the Owner‑Drivers (Contracts and Disputes) Act 2007 section 40(a), (b) or (c) or more than one of those paragraphs)
The grounds on which the referral is made are —
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
(state the name, address and telephone number of owner‑driver and of hirer (if not set out above) and the details of the claim, including any relevant terms of the owner‑driver contract; or any relevant terms of the code of conduct alleged to be breached; or any alleged circumstances of a breach of the Owner‑Drivers (Contracts and Disputes) Act 2007 ; or any relevant conduct complained of in respect of negotiations for an owner‑driver contract — attach schedule if necessary)
			......................................................................
			(signature/seal of applicant or signature of applicant’s solicitor or agent)
(Stamp of Commission)

        [Form 7A inserted in Gazette 10 Jun 2008 p. 2494; amended in Gazette 10 Jul 2009 p. 2742.]

Form 8 — Notice of appeal from Board of Reference

[r. 118(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. .................................			of 20........................
Notice of appeal from Board of Reference
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of respondent/s)
TAKE NOTICE THAT			..........................................................................................
			..........................................................................................
			(name, address and telephone number of appellant/s)
has this day instituted an appeal to the Commission in Court Session against the decision given on the .............................. day of ...................................... 20 ...............
by the Board of Reference constituted for the purposes of
.............................................................................................................................................
(state name and number of award, order, or General Order)
in respect of —
.............................................................................................................................................
.............................................................................................................................................
(state briefly the subject matter of the Board’s decision)
on the ground/s set forth in the attached schedule.
				..............................................................
				.............................................................
				(signature of appellant/s)
This form must be completed by the appellant, signed and, where necessary, sealed by him or her and a statement of the grounds of appeal must be attached. (Stamp of Commission)

        [Form 8 amended in Gazette 10 Jul 2009 p. 2743; 12 Oct 2010 p. 5155.]

Form 9A — Notice of appeal under Vocational Education and Training Act 1996

[r. 101(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. ..............................of 20..........
Notice of appeal under Vocational Education and Training Act 1996
To:	................................................................................................................................ ................................................................................................................................ (name, address and telephone number of respondent/s)
TAKE NOTICE THAT		.........................................................................................
		.........................................................................................
		(name, address and telephone number of appellant/s)
has this day instituted an appeal to the Commission against the decision given on the .................................. day of .......................... 20 ....................
by the chief executive officer of the department principally assisting the Minister to administer the Vocational Education and Training Act 1996 or
...........................................................................................................................................
(state title of person who gave decision)
in respect of —
...........................................................................................................................................
...........................................................................................................................................
(state briefly the subject matter of the decision)
on the ground/s set out in the attached schedule.
				.....................................................................
				(signature of appellant/s)
This form must be completed by the appellant, signed and, where necessary, sealed by him or her and a statement of the grounds of appeal must be attached. (Stamp of Commission)

        [Form 9A inserted in Gazette 16 Jun 2009 p. 2190‑1; amended in Gazette 12 Oct 2010 p. 5155.]

Form 9B — Notice of review of a decision of the Construction Industry Long Service Leave Payments Board

[r. 102A(2)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. ..................................		of 20....................
Notice of review of a decision of the Construction Industry Long Service Leave Payments Board
To:	The Construction Industry Long Service Leave Payments Board
	........................................................................................................................... ................................................................................................................
	(name, address and telephone number of respondent/s)
TAKE NOTICE THAT		......................................................................................
		......................................................................................
		(name, address and telephone number of applicant)
has this day referred the decision of the Construction Industry Long Service Leave Payments Board
..........................................................................................................................
(give details of the decision)
given on the ........................ day of ................................................... 20 ...........
for review to the Commission under the Construction Industry Portable Paid Long Service Leave Act 1985 section 50 on the following grounds:
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
(attach schedule if necessary)
				.....................................................................
				(signature of applicant)
(Stamp of Commission)

        [Form 9B inserted in Gazette 16 Mar 2012 p. 1254‑5.]

Form 9 — Notice of appeal to Full Bench

[r. 99 and 102(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. .................................		of 20........................
Notice of appeal to Full Bench
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of respondent/s)
TAKE NOTICE THAT		..............................................................................................
		..............................................................................................
		(name, address and telephone number of appellant/s)
has this day instituted an appeal against the decision of the Commission constituted by
.............................................................................................................................................
(name of Commissioner, Government School Teachers Tribunal, Public Service Arbitrator, Railways Classification Board)
given on the .................... day of .................................................. 20 .................
in matter numbered ........................................ of ......................... or the following parts or parts of that decision namely:
.............................................................................................................................................
on the ground/s set forth in the attached schedule.
				...........................................................................
				(signature of appellant/s)
The appropriate fee must be paid upon lodgment of this appeal. NOTE 1:         This form must be completed by the appellant, signed and, where necessary, sealed by him or her and a statement of the grounds of appeal must be attached. NOTE 2:         An appeal book in accordance with the Industrial Relations Commission Regulations 2005 must be filed and served on the respondent/s within fourteen (14) days of the filing of this notice. (Stamp of Commission)

        [Form 9 amended in Gazette 10 Jul 2009 p. 2743.]

Form 10 — Notice of appeal to Public Service Arbitrator / Railway Classifications Board

[r. 106(1) and 111(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
					No. .............................				of 20 ...................
Notice of appeal to Public Service Arbitrator / Railway Classifications Board
To:	............................................................................						Tel. No.:			.........................
	............................................................................						Postcode:			.........................
	(name and address of respondent/employer)
TAKE NOTICE THAT				.............................................................................................
				.............................................................................................
				(name, address and telephone number of appellant)
has this day instituted an appeal against the salary/range of salary/title* of the office occupied by me. (*delete whichever is inapplicable)
Particulars of office to which appeal relates			Position No. Section			Classification Branch		Title Division
Claim
Grounds of Appeal
Tick the box if the statement is appropriate — [ ]         An appeal relating to the above position has not been lodged within the last 12 months; [ ]         I wish to represent myself; or [ ]         I authorise the following organisation/person* to act as my agent.
.............................................................................................................................................
(name, address and telephone number of agent)
						......................................................................
						(signature of appellant/s)
The appropriate fee must be paid upon lodgment of this appeal. (Stamp of Commission)

        [Form 10 amended in Gazette 10 Jul 2009 p. 2743.]

Form 11 — Notice of appeal to Public Service Appeal Board

[r. 107(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..................................			of 20........................
Notice of appeal to Public Service Appeal Board
To:	..................................................................................................................................
	..................................................................................................................................
	(name, address and telephone number of respondent/s)
TAKE NOTICE THAT			...........................................................................................
			...........................................................................................
			(name, address and telephone number of appellant/s)
has this day instituted an appeal against the decision .........................................................
.............................................................................................................................................
(give details of the decision)
given on the ........................ day of ................................................... 20 ...........
on the following grounds:
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
(attach schedule if necessary)
				..........................................................................
				(signature of appellant/s)
The appropriate fee must be paid upon lodgment of this appeal. The appellant is required to sign this notice. (Stamp of Commission)

        [Form 11 amended in Gazette 10 Jul 2009 p. 2743.]

Form 12 — Notice of application to enforce the Industrial Relations Act 1979

[r. 60(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
	No. .................................						of 20........................
Notice of application to enforce the Industrial Relations Act 1979
To:	..................................................................................................................................
	..................................................................................................................................
	(name and address of respondent/s)
TAKE NOTICE THAT			..............................................................................................
(Minister / Registrar / Deputy Registrar / Industrial Inspector / Interested person)
has this day applied to the Full Bench of the Western Australian Industrial Relations
Commission for the enforcement of ...................................................................................
(specify part of the Act, direction, order or declaration alleged to be breached)
You are therefore summoned to appear before the Full Bench of the Western Australian Industrial Relations Commission at 111 St George’s Terrace, Perth
in court number ..............................................
on .............................. the ...................... day of .............................................. 20 ...........
(day of the week)		(date)				(month)		(year)
at ....................................... o’clock in the ....................................................... a.m./p.m.
to answer the application for enforcement of that...............................................................
				(Act, direction, order or declaration)
under the Industrial Relations Act 1979 section 84A.
Dated at Perth this ............................. day of ........................................... 20 ..............
					......................................................................
					(signature of applicant)
The appropriate fee must be paid upon lodgment of this application. NOTE:         Where this application is initiated other than by the Registrar it shall be signed and where necessary, sealed by the applicant. (Stamp of Commission)

        [Form 12 amended in Gazette 28 Apr 2006 p. 1653.]

Form 13 — Notice of objection

[r. 15(1), 66(3), 67(3), 68(4), 69(5) and 71(3)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. .............................		of 20 ....................
IN THE MATTER OF an application for		......................................................................................
		(state nature of application)
Notice of objection
Name, address and telephone number of objector	..............................................................................................
The abovenamed objector objects to the whole (or any part) of the abovementioned application.
..............................................................................................................................................
..............................................................................................................................................
(if part only, specify part objected to)
The grounds of objection are:
..............................................................................................................................................
..............................................................................................................................................
(attach schedule if necessary)
The objector is or is likely to be affected by the application in the following manner, namely:
..............................................................................................................................................
..............................................................................................................................................
(attach schedule if necessary)
Dated this ..................................... day of .......................................... 20..............
				.....................................................................
				(signature of objector)
The appropriate fee is to be paid upon lodgment of this notice. (Stamp of Commission)

        [Form 13 inserted in Gazette 28 Apr 2006 p. 1653‑4; amended in Gazette 10 Jul 2009 p. 2743.]

Form 14 — Notice of withdrawal or discontinuance

[r. 16(1) and (4) and 99]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. .............................		of 20 ....................
Notice of withdrawal or discontinuance
To:	...................................................................................................................
	...................................................................................................................
	(name and address of respondent/s)
TAKE NOTICE THAT		.........................................................................................
		.........................................................................................
		(name and address of applicant/s)
the applicant hereby discontinues or withdraws this application or the following part of the claim, namely —
..............................................................................................................................................
(if part only, specify part withdrawn or discontinued)
Dated this .................... day of ............................................ 20..............
				......................................................................
				......................................................................
				(signature of applicant/s)
NOTE:         After being filed, a copy of the notice must be served on every respondent directly affected by it.         Where a counter‑proposal has been filed in answer to an application the application may only be withdrawn or discontinued with the consent of the respondent making the counter‑proposal. (Stamp of Commission)

        [Form 14 inserted in Gazette 28 Apr 2006 p. 1654; amended in Gazette 10 Jul 2009 p. 2743.]

Form 15 — Notice of hearing

[r. 32(2), 99 and 103(8)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
				No. ..............................	of 20 ....................
In the matter of:		[state nature of matter]
Between			..................................................................................................
			(applicant)
and			..................................................................................................
			(respondent)
Notice of hearing
To:	......................................................................................................................
	......................................................................................................................
	(name and address)
TAKE NOTICE that the (insert constitution of Commission) will sit at 111 St. George’s Terrace, Perth in court number .......... on level ......... on .............. at .............. a.m./p.m. to hear the abovementioned matter.
Dated this .................... day of ............................ 20 ..............
Registrar (Stamp of Commission)

        [Form 15 inserted in Gazette 28 Apr 2006 p. 1655.]

Form 16 — Notice to admit

[r. 23(1) and 99]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ...............................	of 20........................
Between		................................................................................................
		(applicant)
and		................................................................................................
		(respondent)
Notice to admit
To:	......................................................................................................................
	......................................................................................................................
	(name and address)
TAKE NOTICE that you are required within 7 days of receiving this notice to admit or deny in writing the following facts —
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
(attach schedule if necessary)
and TAKE FURTHER NOTICE that should you fail to reply to this notice within 7 days or such other time as the Commission upon your application may direct you may be liable to pay the costs of establishing those facts before the Commission.
Dated this ................................. day of ............................................ 20 ..............
...................................................................
...................................................................
(signature of party issuing this notice)
NOTE:         This form must be completed and signed by the party requesting the admission or denial of the facts referred to above. (Stamp of Commission)

        [Form 16 amended in Gazette 28 Apr 2006 p. 1655.]

Form 17 — Summons to witness

[r. 41(1) and 99]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. .....................................	of 20......................
Between			..............................................................................................
			(applicant)
and			..............................................................................................
			(respondent)
Summons to witness
To:	..................................................................................................................................
	..................................................................................................................................
	(full name, occupation and address)
You are summoned to appear before the Commission at ...................................................
on ........................................the .................... day of ............................... 20 ........
at ......................................... o’clock in the ............................................ a.m./p.m.
and after that from day to day until discharged from attendance, to —
(delete if not applicable)		(1)         give evidence concerning the abovementioned matter;         and (2)         produce all books, papers, or other documents in your possession or under your control in any way relating to the proceedings in the said matter and in particular (but not exclusively) the following:
		......................................................................................................................
		......................................................................................................................
This summons has been taken out by..................................................................................
.............................................................................................................................................
(name and address of party taking out summons)
If you fail or neglect to comply with this summons you are liable to a penalty. The appropriate fee must be paid upon lodgment of this summons. (Stamp of Commission)

Form 18 — Warrant to appear as agent

[r. 63(1) and (3) and 99]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ...................................			of 20........................
Between			..........................................................................................
			(applicant)
and			..........................................................................................
			(respondent)
Warrant to appear as agent
.............................................................................................................................................
.............................................................................................................................................
	(insert name, address and telephone number of agent)
is hereby authorised to appear and act, in the abovementioned proceedings, for
.............................................................................................................................................
.............................................................................................................................................
(name of party for whom agent is appearing and acting)
This warrant also authorises the agent to receive mail, including email or fax, from the Commission for and on behalf of the party for whom the agent is appearing and acting.
(delete if not applicable)
(affix seal where necessary)				.................................................................
				(signature of party for whom the agent is appearing)
Dated this ................................. day of ............................................ 20 ..............
This warrant must be served on all other parties to the application for which the warrant is filed. (Stamp of Commission)

        [Form 18 amended in Gazette 28 Apr 2006 p. 1655-6; 10 Jul 2009 p. 2743.]

Form 19 — Application for registration of organisation/association

[r. 66(1), 67(1) and 68(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
	No. .................................		of 20.............................
Application for registration of organisation/association
To the Registrar:
An application for registration under Part II Division 4 of the Industrial Relations Act 1979 is made by —
.............................................................................................................................................
.............................................................................................................................................
(name of organisation/association)
The following documents are lodged in support of this application —
(1)         a list containing the full names and addresses of officers of the organisation/association;         (2)         a certified copy of the rules of the organisation/association;         (3)         a copy of the resolution authorising the application.
The registered office of the organisation/association will be situated at —
.............................................................................................................................................
.............................................................................................................................................
		............................................................................
		(name and telephone number of person signing for and on behalf of the organisation/association)
Dated at Perth this ............................. day of ................................... 20 ................
The appropriate fee must be paid upon lodgment of this application. (Stamp of Commission)

        [Form 19 amended in Gazette 10 Jul 2009 p. 2744.]

Form 20 — Application to register additions, alterations or revisions of the name or rules of a registered organisation or association

[r. 69(1) and (2), 70(1) and (2) and 71(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
			No. ..............................		of 20 ......................
Application to register additions, alterations or revisions of the name or rules of a registered organisation or association
To the Full Bench/Registrar:
An application is made by —
.............................................................................................................................................
.............................................................................................................................................
	(name of organisation/association)
an organisation/association registered under the Industrial Relations Act 1979 for the registration or alteration to the name/rules of the organisation/association, the particulars of which are attached to this Form. The alterations were proposed by the organisation/association in accordance with its rules and the Act on —
..........................................................................
(date alterations were proposed)
		.......................................................................................
		(name and telephone number of person signing for and on behalf of the organisation/association)
Dated at Perth this ............................ day of .................................. 20 ................
The appropriate fee must be paid upon lodgment of this application. (Stamp of Commission)

        [Form 20 amended in Gazette 10 Jul 2009 p. 2744.]

Form 21 — Summons for cancellation or suspension of registration of organisation/association

[r. 74(2)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. .............................		of 20 ........................
Summons for cancellation or suspension of registration of organisation/association
To:	........................................................................................................................
	........................................................................................................................
	(name and address of organisation/association)
TAKE NOTICE that you are required to appear before the Full Bench of the Western Australian Industrial Relations Commission at 111 St George’s Terrace, Perth
on ...................................the .................. day of ............................................ 20 .............
at ....................................... o’clock in the ....................................................... a.m./p.m.
and after that as required, to show cause why the registration of the organisation should not be cancelled or suspended under the Industrial Relations Act 1979 section 73.
Dated at Perth this .............................. day of ................................... 20 ................
			..............................................................
			(signature of Registrar)
(Stamp of Commission)

Form 22 — Request by an organisation/association to cancel its registration

[r. 75(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
	No. ..................................			of 20.............................
Request by an organisation/association to cancel its registration
To the Registrar:
A request is made by —
.............................................................................................................................................
.............................................................................................................................................
(name of organisation/association)
an organisation/association registered under the Industrial Relations Act 1979 for the cancellation of that registration.
The grounds on which the request is made are:
.............................................................................................................................................
.............................................................................................................................................
(attach schedule if necessary)
The number of members whose names are at present lawfully on the register of members kept by the organisation/association is ................................................................
The number of members present at the meeting which resolved to seek the cancellation/suspension of the organisation/association was					..............................
The number in favour of this action was			..........................
		...............................................................................
		(name and telephone number of person signing for and on behalf of the organisation/association)
Dated at Perth this .............................. day of ................................ 20 ................
(Stamp of Commission)

        [Form 22 amended in Gazette 28 Apr 2006 p. 1656; 10 Jul 2009 p. 2744.]

Form 23 — Application to cancel registration of organisation/association

[r. 76(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. .............................		of 20 ........................
Application to cancel registration of organisation/association
To:	...............................................................................................................................
	...............................................................................................................................
	(name and address of organisation/association)
TAKE NOTICE that that the Registrar has this day applied to have the registration of —
.............................................................................................................................................
(name of organisation/association)
cancelled on the following grounds —
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
(grounds for cancellation)
AND TAKE NOTICE that notice of any objection to the cancellation must be given in writing in accordance with Form 13 within 14 days of the service of this application.
Dated at Perth this ........................... day of .................................... 20 ................
			.......................................................................
			(signature of Registrar)
(Stamp of Commission)

        [Form 23 amended in Gazette 28 Apr 2006 p. 1656.]

Form 24 — Certificate of registration as an organisation

[r. 77(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
Certificate of registration as an organisation
I certify that the organisation called —
.............................................................................................................................................
(name of organisation)
whose registered office is at —
.............................................................................................................................................
(address of organisation)
has this day been duly registered as an organisation under the Industrial Relations Act 1979 , and, under section 60 of that Act, is a body corporate.
Given under my hand this ........................... day of ......................... 20 ..............
	..............................................................................
	(signature of Registrar)
(Stamp of Commission)

Form 25 — Certificate of registration as an industrial association

[r. 77(2)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
Certificate of registration as an industrial association
I certify that the association called —
.............................................................................................................................................
(name of association)
whose registered office is at —
.............................................................................................................................................
(address of association)
has this day been duly registered as an industrial association under the Industrial Relations Act 1979 , and, pursuant to sections 60 and 67 of that Act, is a body corporate.
Given under my hand this ........................ day of ........................... 20 ................
	............................................................................
	(signature of Registrar)
(Stamp of Commission)

Form 26 — Certificate of registration as an organisation formed by amalgamation

[r. 77(3)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
Certificate of registration as an organisation formed by amalgamation
I certify that the organisations formerly registered under the names —
1 ..........................................................................................................................................
(organisation)
2 ..........................................................................................................................................
(organisation)
have this day been duly registered under the Industrial Relations Act 1979 , as one organisation by the name —
.............................................................................................................................................
(organisation)
and that organisation is, pursuant to section 60 of that Act, a body corporate. The registrations of the organisations referred to in items 1 and 2 above are this day cancelled.
Given under my hand this ........................ day of ........................... 20 ................
	..............................................................................
	(signature of Registrar)
(Stamp of Commission)

Form 27 — Certificate of registration of alteration of rules

[r. 77(4)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
Certificate of registration of alteration of rules
I certify that the annexed alteration of rules of —
.............................................................................................................................................
(organisation/association)
have this day been duly registered at my office under the provisions of the Industrial Relations Act 1979 .
The rules altered are —
.............................................................................................................................................
Given under my hand this ........................ day of ............................... 20 .............
	..............................................................................
	(signature of Registrar)
(Stamp of Commission)

Form 28 — Certificate of registration of change of name

[r. 77(5)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
Certificate of registration of change of name
I certify that on ................................. day of ............................................. 20 ...................
on the hearing of an application duly made on behalf of the organisation/association formerly registered under the title of —
.............................................................................................................................................
(organisation/association)
the Full Bench consented to the name of the organisation/association being changed to read, and that name is accordingly now registered as —
.............................................................................................................................................
Given under my hand this ........................ day of .................................... 20 .............
	...............................................................................
	(signature of Registrar)
(Stamp of Commission)

Form 29 — Application by secretary for authority to be issued

[r. 82(1)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
	No. ..............................		of 20.............................
Application by secretary for authority to be issued
To the Registrar:
An application is made by —
.............................................................................................................................................
(name of secretary of organisation)
the secretary of —
.............................................................................................................................................
.............................................................................................................................................
(name, address and telephone number of organisation)
for the issue of an authority under section 49J of the Industrial Relations Act 1979 to the following person —
.............................................................................................................................................
.............................................................................................................................................
(name, address and telephone number of person)
		.....................................................................................
		(signature of organisation secretary)
Dated at Perth this........................... day of ......................................... 20 ................

        [Form 29 amended in Gazette 10 Jul 2009 p. 2744.]

Form 30 — Application by secretary for revocation of an authority

[r. 82(2)]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..............................	of 20.............................
Application by secretary for revocation of an authority
To the Registrar:
An application is made under section 49J(6) of the Industrial Relations Act 1979 by —
.............................................................................................................................................
(name of secretary of organisation)
the secretary of —
.............................................................................................................................................
.............................................................................................................................................
(name, address and telephone number of organisation)
for the revocation of an authority issued under section 49J of that Act to —
.............................................................................................................................................
.............................................................................................................................................
(name, address and telephone number of person)
	..................................................................................
	(signature of organisation secretary)
Dated at Perth this................................. day of .................................... 20 ................

        [Form 30 amended in Gazette 28 Apr 2006 p. 1656; 10 Jul 2009 p. 2744.]

Form 31 — Notice of appeal against a decision of the Commissioner of Police to take removal action

[r. 90]

        [Heading amended in Gazette 22 Dec 2009 p. 5272.]

Industrial Relations Act 1979
In the Western Australian Industrial Relations Commission
		No. ..................................		of 20........................
Notice of appeal against a decision of the Commissioner of Police to take removal action
To the Commissioner of Police
TAKE NOTICE THAT	...........................................................................................
	...........................................................................................
	(name, address and telephone number of appellant/s)
has this day instituted an appeal under section 33P of the Police Act 1892 against your decision under section 33L of that Act to remove him/her from office with effect from —
the .............................................. day of ............................................................ 20 ...........
The reasons why the decision is harsh, oppressive or unfair are —
.............................................................................................................................................
.............................................................................................................................................
(give details of the decision — attach schedule if necessary)
The relief sought is .............................................................................................................
(state whether the removal is sought to be of no effect or whether compensation is sought)
			..................................................................
			(signature of appellant/s)
NOTE1:         This Notice of appeal is to be served by the appellant upon the Commissioner of Police within 7 days after it is filed in the office of the Registrar. NOTE2:         Proof of service of the notice on the Commissioner of Police is to be given in accordance with the Industrial Relations Commission Regulations 2005 regulation 28. (Stamp of Commission)

        [Form 31 amended in Gazette 10 Jul 2009 p. 2744; 22 Dec 2009 p. 5272.]