FORM JA
(subregulation 20A(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 44K(1) of the Competition and Consumer Act 2010, for a review of the declaration of a service by the designated Minister, (full name and designation of the designated Minister), under subsection 44H(1) of the Act;
	* under subsection 44K(2) of the Competition and Consumer Act 2010, for a review of the declaration by the designated Minister, (full name and designation of the designated Minister), under subsection 44H(1) of the Act, not to declare a service;
	* under subsection 44L(1) of the Competition and Consumer Act 2010, for a review of the declaration by the designated Minister, (full name and designation of the designated Minister), under subsection 44J(3) of the Act, not to revoke the declaration of a service;

	being the service described below.

2.	I am
	* the provider.
	* the person who applied for the declaration recommendation.

3.	Brief description of the service:

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

5.	Issues as I see them:

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

Dated this						day of 				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 solicitor for applicant this fact should be stated.)

* Delete if not applicable.

History
Form JA inserted by SR No 20 of 1996, reg 10.4, 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).