FORM L
(subregulation 28C(1))
APPLICATION TO TRIBUNAL FOR REVIEW
(Title)

Name of applicant:
Address of applicant:
(If the applicant is a corporation, give the corporation’s name and address, not the name and address of an officer of the corporation).

1.	I apply to the Australian Competition Tribunal under subsection 44ZP(1) of the Competition and Consumer Act 2010 for a review of a determination of the Australian Competition and Consumer Commission on access to the service described below.

2.	I am
		*the provider.
		*the third party.
		*a party to the determination, other than the provider or the third party.

3.	Brief description of the service:

4.	Facts and contention on which I intend to rely:

5.	Issues as I see them:

6.	Address for service of documents:
(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).
* Delete if not applicable

History
Form L inserted by SR No 20 of 1996, reg 10.6, effective 31
January 1996; amended by SR No 280 of 2010, Sch 1, effective 1 January 2011 (as amended by SR No 337 of 2010).