Application for review of decision

Instructions for completion

ACMA form – R051Page 1 of 2June 2011

  • Print clearly. Illegible, unclear or incomplete application forms may delay processing.
  • If there is not enough space on this form, please attach a separate sheet, clearly identifying the question(s) to which it refers.
  • Under subsection 288(4) of the Radiocommunications Act 1992, a statutory declaration may be required.

Where to send this form

  • Completed forms should be forwarded to:

Radiocommunications Licensing and Telecommunications Deployment Section, Operations Branch

Australian Communications and Media Authority

PO Box 78

Belconnen ACT2616

Telephone: 1300 850 115

Facsimile: (02) 6219 5347

Email:

ACMA form – R051Page 1 of 2June 2011

Applicant’s details

ACMA form – R051Page 1 of 2June 2011

Customer number (if known)

Name

SURNAME
GIVEN NAMES

Company name and ACN

COMPANY NAME
ACN:

Trading name

Postal address

POSTCODE

Contact details

WORK ( )
HOME ( )
MOBILE
FACSIMILE ( )

ACMA form – R051Page 1 of 2June 2011

Under section 285 of the Radiocommunications Act 1992, I wish to make an application to the ACMA for reconsideration of the decision indicated below (tick appropriate box). Reasons for the request are documented on the reverse of this form.

ACMA form – R051Page 1 of 2June 2011

( ) Variation of a Spectrum Licence (section 73 or 87 or paragraph 92(2)(b))

( ) Suspension of a Spectrum Licence (section 75)

( ) Cancellation of a spectrum Licence (section 77 or 87)

( ) Change in the core conditions of a Spectrum Licence on its reissue (section 82)

( ) Refusal to issue an Apparatus Licence (section 100)

( ) Refusal to issue a transmitter licence (section 101A)

( ) Refusal to issue a datacasting transmitter licence (section 101B) otherwise than because of a decision (paragraph 102B(b)

( ) Inclusion of conditions in an Apparatus Licence (paragraph 107(1)(g), 108A(1)(f), 109(1)(f), 109A(1)(k) or 109B(1)(t))

( ) A decision concerning the conditions of an Apparatus Licence (section 111)

( ) Direction under subsection 116(1) to revoke an authorisation (section 114)

( ) Refusal to issue a Certificate of Proficiency (section 121)

( ) Cancellation of a Certificate of Proficiency (section 124)

( ) Suspension of an Apparatus Licence (section 126)

( ) Cancellation of an Apparatus Licence (section 128)

( ) Refusal to renew an Apparatus Licence, or renewal of an Apparatus Licence with different conditions (section 130)

( ) Refusal to transfer an apparatus licence (section 131AB) otherwise than because of a decision (paragraph 131ACA(b)

( ) Refusal to issue a provisional international broadcasting certificate (section 131AF)

( ) Refusal to include in the Register details of a radiocommunications transmitter (section 145)

( ) Refusal to correct the register (section 153)

( ) Refusal to issue a Permit (section 167)

( ) Decision about the conditions of a Permit (section 168)

( ) Giving a notice (subsection 169(6))

( ) Cancellation of a Permit (section 171)

( ) Refusal to give permission to supply a non-standard device (section 174)

( ) Refusal to give permission to use a transmitter (subsection 193(1) or 195(1))

( ) Directions in relation to the settlement of an interference dispute (section 212)

( ) Refusal to give to a person an accreditation (section 263)

( ) Withdrawal of a person’s accreditation (section 264)

( ) Making of a pre-acquisition declaration (Part 1 of the Schedule

ACMA form – R051Page 1 of 2June 2011

Declaration

ACMA form – R051Page 1 of 2June 2011

I declare that to the best of my knowledge the information given in the application is accurate and complete.

SIGNATURE / POSITION IN ORGANISATION (IF APPLICABLE)
PRINT NAME / DATE

ACMA decision

ReferenceDate

...... /…………./…………

Explanatory detail

Reasons for reconsideration

ACMA form – R051Page 1 of 2June 2011