FORM LA
(subregulation 28C(1A))
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, give the corporation’s name and address, not the name and address of an officer of the corporation).

1.	Application is made to the Australian Competition Tribunal under subsection 152DO(1) of the Competition and Consumer Act 2010 for a review of a determination of the Australian Competition and Consumer Commission about access to the declared service described below.
2.	This application is made by [the access provider]* [the access seeker]* [a party to the determination who is not the access provider or seeker]*.
3.	The declared service to which the access undertaking relates is:
(describe the service briefly).
4.	The facts and contention on which this application relies are as follows:
(state the facts and contentions briefly).
5.	The issues in reliance on which this application is made are as follows:
(state the issues briefly).
6.	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 the signatory in the corporation.  If the signatory is a solicitor for the applicant, state that fact).

* Omit if inapplicable

History
Form LA inserted by SR No 322 of 1997, reg 10.3, 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).