Form 71 v1

Form 71
Version 1
Application to revoke WHS entry permit
Work Health and Safety Act 2011, section 138
R.85
(To be used for applying to the Commission for a WHS entry permit held by a
person to be revoked.)
QUEENSLAND INDUSTRIAL RELATIONS COMMISSION
Work Health and Safety Act 2011, section 138
(name of applicant)
AND
(name of respondent)
(Matter No.
/20
/
)
APPLICATION TO REVOKE WHS ENTRY PERMIT
TO:
The Industrial Registrar, Industrial Registry, Level 21, Central Plaza 2, 66 Eagle Street, (Corner Creek
and Elizabeth Streets), Brisbane 4000, GPO Box 373, Brisbane Q 4001
Phone: (07) 3227 8060 Fax: (07) 3221 6074
AND TO:
of
(WHS permit holder)
(address)
AND TO: President/Secretary of
of
(name of employee organisation the WHS permit holder represents)
TAKE NOTICE that I,
(address)
[the regulator] or [relevant person
(applicant’s name)
conducting business or undertaking] or [a person in relation to whom the WHS entry permit
holder has exercised or purported to exercise a right] or [a person affected by the exercise or purported exercise
of a right under this part by a WHS entry permit holder] of
(address)
APPLY to the commission under section 138 of the Work Health and Safety Act 2011 for a WHS entry permit
held by the respondent to be revoked.
1. The grounds for the application are:
(See section 138(2) - briefly state the ground(s) on which you are appling to have the WHS permit revoked)
(a)
(b)
(c)
2. The decision sought is:
(a) (For an order imposing conditions on the WHS entry permit – set out conditions)
(b) (For an order suspending the WHS entry permit – terms of the proposed order)
(c) (For an order revoking the WHS entry permit – the proposed order)
(d) (For an order about the future issue of a WHS entry permit to the person whose WHS entry permit has been
revoked – terms of the order)
(e) (Terms or any alternative action proposed)
3. [Further application is make for directions as to the conduct of this application in relation to the following
matters -]
[(a) place and time of hearing;]
Form 71, R. 85.
[(b)
.]
(any other directions required)
4. Further, I ,
[make oath and say] [solemnly and sincerely affirm and
(if a representative - capacity and authority to make the affidavit, R.11(b))
declare] as follows (a)
(b)
(State concisely and in consecutively numbered paragraphs the material facts relied on to support the application
and any other matters required under R. 10.)
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.
(if the affidavit extends over more than 1 page, at the foot of the first and every other page except the last:)
[Page 1]
[Signed
[Taken by
(deponent to sign)
]
(person before whom affidavit is sworn]
(At the end of the body of the affidavit:)
(Signature)
Deponent
[SWORN] [AFFIRMED] by the deponent at
on
(place)
(day, month and year)
before me:
(Signature)
(print name)
[Justice of the peace][commissioner for declarations][lawyer](other)
TO RESPONDENTS:
TAKE NOTICE that if you wish to oppose this application or to argue that any different decision should
be made, you must attend before the commission in person or, if appropriate, by your lawyer or agent at
the time on the date and at the place fixed by the registrar and you will be heard. If you do not attend as
required a decision may be given against you in terms of the decision sought and costs, where
appropriate, without further reference to you.
(Last page)
PARTICULARS OF THE APPLICANT
Name:
Position or title: (if applicable)
Organisation, corporation, association, department etc: (if applicable)
Residential or business address:
Appellant’s address for service:
Appellant’s phone number or contact phone number:
Appellant’s fax number: (if any)
Appellant’s e-mail address: (if any)
[IF APPLICANT HAS A LAWYER
Appellant’s lawyer’s name:
and firm name:
Lawyer’s business address:
Address for service:
Phone:
Fax:
E-mail address: (if any]
[IF APPLICANT HAS AN AGENT (An appointment of agent form must accompany this application, R 13(1)(l))
Appellant’s agent’s name:
and corporation or business name:
Agent’s business address:
Address for service:
Phone:
Fax:
E-mail address: (if any)]
PARTICULARS OF THE RESPONDENTS (if there is more than 1 respondent this information must be given for all
respondents)
Name:
Position or title: (if applicable)
Organisation, corporation, association, department etc: (if applicable)
Residential or business address:
Respondent’s address for service:
Respondent’s phone or contact phone number:
Respondent’s fax number: (if any)
Respondent’s e-mail address: (if any)
[IF RESPONDENT HAS A LAWYER
Respondent’s lawyer’s name:
and firm name:
Lawyer’s business address:
Address for service:
Phone:
Fax:
E-mail address: (if any)]
[IF RESPONDENT HAS AN AGENT
Respondent’s agent’s name:
and corporation or business name:
Agent’s business address:
Address for service:
Phone:
Fax:
E-mail address: (if any)]