Prescribed Form 10

WRITTEN STATEMENT BY PARTICIPANT
CHALLENGING A DECISION ON THE BASIS OF
EXCEPTIONAL CIRCUMSTANCES (SECTION 7.4)
Prescribed Form 10

Your Details

Full Name*

First NameLast Name

FFA Number*

Club Name*

Match Details

Opposition Team*

League*

Grade*

Date & Kick off time*

MonthDayYearHourMinutesAM/PM Option

Submission

1. I, hereby give notice to the Disciplinary Committee that there are exceptional circumstances operating at the time of the Offence.

2. Those exceptional circumstances are listed below:

Please insert grounds you wish to rely upon;*

Refer to Section 7.4 of the Regulations on what constitutes Exceptional Circumstances

1. None of the grounds listed in paragraph 2 above are those listed in section 7.4(c) of the CDSFA Grievance and Disciplinary Regulations (Regulations).

2. I declare that the information in this statement is accurate and to the best of my knowledge.

3. I acknowledge that I may be charged with Misconduct if it is established that the contents of this statement are incorrect and amount to an abuse of process.

Notes:

1. Please submit this form by 4pm the next working day after the issuance of the Notice of Suspension to the Club by the CDSFA.

2. In addition to submitting this form, please submit any other evidence which may support your challenge.

3. Participants should read and consider section 7.4 prior to signing and lodging this form with the Disciplinary Committee.

4. If the CDSFA does not receive a properly completed form by the time specified in paragraph 1, you are deemed to have committed the Offence.

5. Capitalised words used in this document are defined in the Regulations.

Submitter Details

Your name*

First NameLast Name

Your E-mail*

A copy of your submission will be emailed to this address.

Digital Signature*

I certify that the information entered above is true and correct and was entered by myself.

Submission Date*

DayMonthYear