South Australian Employment Tribunal

Form A30 – Application - Unfair dismissal

Form A30

Application - Unfair dismissal

Case Number
(SAET use only)

About this form

  • This is the approved form for lodging an unfair dismissal application with SAET in accordance with section 106 of the Fair Work Act 1994.
  • Regulations made under the Fair Work Act 1994 exclude certain employees from applying to SAET in respect of their termination of employment.
  • An application must be lodged before the end of 21 days from the date the dismissal took effect. An application for extension of time can be made in this form.
  • The Act provides for SAET to make an order for costs against either the employee or employer in certain circumstances.
  • Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Name of Case and Parties Names

IN THE MATTER of an application pursuant to Section 106 of the Fair Work Act 1994 between:

Applicant (employee)
Respondent(employer)

Party details

Employee / Applicant

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Do you require an interpreter? / ☐ No ☐ Yes. Please specify language:
Do you have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:

Employer / Respondent

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

About your Employment

Type of work performed for your employer
Work addressStreet 1
Street 2
Suburb / State
Postcode / Country
Date when you first worked for employer
Date termination of employment took effect
Did you receive written notice of termination or a separation certificate? / ☐ No ☐ Yes - please provide a copy

Categories of employment

Name of Award and Agreement you were employed under (if known)
Were you serving a period of probation or qualifying period of employment at the time of your dismissal? / ☐ No ☐ Yes
Type of employment
(mark all relevant boxes) / ☐ Full-time
☐ Part-time
☐ Casual
☐ Apprenticeship or traineeship
☐ Contract of employment for a specified period or task

Reasons for application

Brief summary of reasons given by employer for the termination and explain why you say your dismissal is harsh, unjust or unreasonable.

Attach further pages if required. Only brief details are required. You will have an opportunity to expand on these reasons at the conciliation conference, or later at arbitration if required.

remedy sought

What remedy are you seeking?
(mark all relevant boxes) / ☐Re-employment to your former position
☐Re-employment to some other position (specify)
☐Monetary compensation (specify amount) / S

Extension of time

Will this application be lodged within 21 days after the date the dismissal took effect?

☐Yes – continue to next question

☐No – SAET must decide whether or not to extend the time limit.

I apply for an extension of time in which to make this unfair dismissal application. Please provide justification below.

Representation

Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Other proceedings

Have you, or do you intend to initiate, other proceedings concerning this employer under this or any other Act or with SAET?

☐ No ☐ Yes. Please specify:

LODGING YOUR COMPLETED FORM

I declare that all of the facts in this application are true and accurate to the best of my knowledge and belief:

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

SAET Registry: 08 8207 0999