FORM JD
(subregulation 20A(4))
APPLICATION FOR REVIEW BY AUSTRALIAN COMPETITION TRIBUNAL
Commonwealth of Australia
Competition and Consumer Act 2010
(Title of matter)

Name of applicant:	(insert full name of applicant)
Address of applicant:	(insert address of applicant)
(If the applicant is a corporation, the corporation’s name and address should be inserted here, not the name and address of an officer of the corporation).

1.	Application is made to the Australian Competition Tribunal under subsection 152AV(1) of the Competition and Consumer Act 2010 for review of a decision of the Australian Competition and Consumer Commission under section 152AT of that Act to grant, or refuse to grant, an exemption order to (insert name of applicant for the order) from an obligation, or obligations, under section 152AR of the Act.

2.	The declared service to which the application for the exemption order relates is:
(describe the service briefly).

3.	The standard access obligations to which the application for the exemption order relates are:
(state the obligations briefly).

4.	Particulars of the effect of the Commission decision on the interests of the applicant for the review are as follows:
(state the particulars briefly).
5.	The facts and contentions on which this application relies are as follows:
(state the facts and contentions briefly).

6.	The issues in reliance on which this application is made are as follows:
(state the issues briefly).

7.	Address for service of documents:
(insert address for service)
(An address for service must comply with regulation 21 of the Competition and Consumer Regulations 2010).

Dated:					20		Signed by/on behalf of the applicant:
(Signature)
(Full name)
………….………………………………
(If applicant is a corporation, state position occupied in corporation by person signing.  If signed by a solicitor for applicant this fact should be stated).

History
Form JD inserted by SR No 322 of 1997, reg 10.2, effective 
27 November 1997; amended by SR No 280 of 2010, Sch 1, 
effective 1 January 2011 (as amended by SR No 337 of 2010).