(PF 10) GRIEVANCE FORM

GRIEVANCE FORM (SECTION 8.3)
Prescribed Form 10

APPLICANT DETAILS

Member Applicant*

FFA Number

If applicable

E-mail Address*

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

TYPE OF APPLICATION

Is your application in reference to a “claim” or “complaint”?*

ClaimComplaint

RESPONDENT DETAILS

Member Respondent*

FFA Number

If applicable

Respondent E-mail

If there are further parties who are Respondents, please provide their details below.

AFFECTED PARTY

Your application for relief may have consequences for another party. BDSFA is concerned to ensure such as the Affected Party (including BDSFA) is aware of your application and is provided with an opportunity to be heard.

Is there another party potentially directly affected by your appeal? *

YesNo

Please provide the name and contact details of the affected party.

REPRESENTATION

Do you wish to be represented by a support person of the Club? *

YesNo

Please provide name and contact details of Club representative

Do you wish to be represented by a lawyer?*

YesNo

Please provide name and contact details of the legal representative

JURISDICTION

Does the General Purpose Tribunal have jurisdiction to hear this matter?*

YesNo

DATE GRIEVANCE ROSE

Grievance date *

DayMonthYear

If you wish to, provide a timeline of events below.

DETAILS OF THE GRIEVANCE

Briefly state the relevant facts and legal arguments including any relevant sections in the FFA Rules and Regulations, Football NSW Rules and Regulations or the Association’s rules and regulations that may apply.

You must include a clear statement of the issues you are submitting.

Please submit all documents that have been provided by each party under section 8.3 of the Regulations

Upload a File

Max file size 4MB. Allowed files types pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, jpg, jpeg, png, gif

RELIEF SOUGHT

Please describe the relief that you are seeking*

Notes:

1. Please submit this form within 14 working days after the dispatch of the notice referred to in section 9.3(c).

2. Please lodge a fee of $500 together with this Form. Payment can be made by cheque or direct debit into BDSFA's bank account. Bank: Commonwealth Bank Ltd, Account Name: Blacktown & Districts Soccer Football Association, BSB: 062 121, Account Number: 00909770. Please file receipt of payment into this account with the Tribunal Administrator at admin@bdsfa.com

3. Members should read and consider sections 8, 11 and 12 of the Regulations prior to signing and lodging this Form to the BDSFA.

4. Pursuant to section 9.3 of the Regulations, your Claim or Complaint will be dealt with by mediation (section 12 of the Regulations) in the first instance unless BDSFA believes that the claim or complaint should be referred to a GPT.

5. If BDSFA does not receive a properly completed Form by the time specified in paragraph 1 together with the $500 fee, you waive your right to have the matter heard at BDSFA.

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

SUBMISSION

Your name*

First NameLast Name

Digital Signature*

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

Submission Date*

DayMonthYear