National Banning Regulations – Application Form /

FFA NATIONAL BANNING REGULATIONS

APPLICATION FORM
Banning Appeal to FIBAC for bans issued post 15 February 2016

FOOTBALL FEDERATION AUSTRALIA

Level 22, 1 Oxford Street, Darlinghurst NSW 2010

Locked Bag A4071, Sydney South NSW 1235

Telephone:+61 (2) 8020 4000

Facsimile:+61 (2) 8020 4100

15 February 2016 / 1
National Banning Regulations – Application Form /

Your privacy: FFA collects your personal information so we can administer the National Banning Regulations and the Football Independent Banning Appeal Committee. You have a right to access certain personal information that we collect and hold about you. You may contact us at . A copy of the FFA privacy policy is available at .

  1. APPLICANT DETAILS

Name:
Address for service of notices:
Telephone:
Mobile:
Fax:
Email:
  1. CLUB DETAILS

Are you a registered member of an A-League Club or W-League Club?

Yes [ ] No [ ]

If your answer is yes, please name that club:

Name of Club:
  1. BANNING NOTICE

You must include a copy of the Banning Notice being appealed and confirm the date of the Banning Notice:

Date of Banning Notice: / D D/ M M/ Y E A R
  1. APPEAL
  2. Grounds of appeal

The sole grounds of appeal to the Football Independent Banning Appeal Committee are as set out in clause 7.3 of the National Banning Regulations. On what ground/s are you appealing FFA’s decision to impose a ban:

/ I was not afforded a reasonable opportunity to be heard on the issues of merit and/or ban;
/ FFA’s decision was affected by bias;
/ FFA’s decision was one that was not reasonably open to FFA having regard to the evidence before FFA.

4.2Statement

You mustprovide a statement setting out the basis upon which you are contesting the ban that has been imposed (which must be limited to the grounds of appeal provided for above) including any written submissions, materials, documents or other evidence that you intend to rely on. If necessary, continue in an annexure:

  1. RELIEF SOUGHT

Please nominate the relief you are seeking from the Football Independent Banning Appeal Committee:

/ Set aside the decision of FFA to impose the ban; or
/ Vary the decision of FFA by the imposition of a lesser ban.

If you are requesting the Football Independent Banning Appeal Committee to vary the decision of FFA by the imposition of a lesser ban, you mustprovide a statement setting out the basis upon which you are making such a request including any written submissions, materials, documents or other evidence that you intend to rely on as well as the length of ban that you consider to be appropriate. If necessary, continue in an annexure:

  1. INSTRUCTIONS FOR LODGING APPLICATION

You should address any correspondence, applications or other general queries to the Administrator at the address below:

Football Federation Australia Limited

Level 22, 1 Oxford Street, Darlinghurst NSW 2010

Locked Bag A4071, Sydney South NSW 1235

Ph: (02) 8020 4000

Fax: (02) 8020 4100

  1. SIGNATURE OF APPLICANT

By submitting this Application Form, you:

(a)acknowledge and agree to be bound by and comply with the FFA National Banning Regulations;

(b)agree to release each member of the Football Independent Banning Appeal Committee from all liability arising directly or indirectly out of or in connection with the determination of this Application;

(c)agree not to bring any claim or proceeding against a member of the Football Independent Banning Appeal Committee for any damage, loss, injury or liability you may suffer arising directly or indirectly out of or in connection with the determination of this Application;

(d)warrant that the information contained in this Application Form is true and correct.

Signed:
Name:
Date: / D D/ M M/ Y E A R
15 February 2016 / 1