IN THE FEDERAL CIRCUIT AND	File number: .....................................
FAMILY COURT OF AUSTRALIA
REGISTRY: ........................................................
......................................................................
Applicant
.....................................................................
Respondent
Repeat as necessary for additional parties
Form 3
Fair Work Division
Rule 30.05(b)	Claim under the Fair Work Act 2009 alleging unlawful termination of employment	

Part A – Details of employee	
1. Name	Mr 	Mrs 	Ms 
Other   (give details):  ...................................................................
Family name:	...................................................................................
Given names:	...................................................................................	
2. Address	............................................................................................................................................................................................................................................................................................	Postcode:....................	
3. Phone	Business hours:	(.....) ...............................
After hours:	(.....) ...............................
Mobile:	........................................	
4. Date of birth	............/............/...........	
5. First language		English
	Other (specify):	.....................................................................	

Part B – Details of employment	
6. Employer’s name	     	
7. Employer’s trading address or registered office	...........................................................................................................................................................................................................................................................................................Postcode:...................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	
8. Work performed for employer (occupation)	     	
9. Place of work
	...........................................................................................................................................................................................................................................................................................Postcode:...................	
10. Period of employment	Date started work:	............/............/...........
Last date worked:	............/............/...........	
11. Was the employee given a written notice of termination?		No
	Yes -  Copy attached	

Part C – If the applicant is an individual – details of representation	
12. Is a union acting on your behalf?		No - go to 19
	Yes - go to 13	
13. Name of union	     	
14. Address	...........................................................................................................................................................................................................................................................................................Postcode:......................	
15. Contact person 	Name:.................................................................................................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

Part D – If the applicant is an industrial association – details of representation	
16. Is a member, officer or employee of the applicant representing the applicant?		No - go to 19
	Yes - go to 17	
17. Name of the member, officer or employee	     	
18. Address	...........................................................................................................................................................................................................................................................................................Postcode:......................	

Part E – Details of lawyer	
19. Is a lawyer representing you?		No - go to 23
	Yes - go to 20	
20. Lawyer’s name	     	
21. Name of lawyer’s firm	     	
22. Address	.....................................................................................................................
..............................................................................Postcode:	......................
DX:	........................................
Phone:	(.....) ...............................
Fax:	(.....) ...............................	

Part F – Notices from the Court	
23. Where do you want notices from the Court sent?		address in 2
	union in 13‑15
	address in 17‑18
	lawyer in 20-22
	other (give details):	..............................................................................	

Part G – Grounds of the claim of unlawful termination	
24. What are the grounds for the claim that the employee’s employment was unlawfully terminated?
	Termination of the employee’s employment for one or more of the following reasons, or for reasons including one or more of the following reasons:
	temporary absence from work because of illness or injury of a kind prescribed by the regulations
	trade union membership or participation in trade union activities outside working hours or, with the employer’s consent, during working hours
	non‑membership of a trade union
	seeking office as, or acting or having acted in the capacity of, a representative of employees
	the filing of a complaint, or the participation in proceedings, against an employer involving alleged violation of laws or regulations or recourse to competent administrative authorities
	race, colour, sex, sexual preference, age, physical or mental disability, marital status, family or carer’s responsibilities, pregnancy, religion, political opinion, national extraction or social origin
	absence from work during maternity leave or other parental leave
	temporary absence from work for the purpose of engaging in a voluntary emergency management activity, where the absence is reasonable having regard to all the circumstances
	Other
	
25 Details of the claim of unlawful termination of employment
(Set out in numbered paragraphs the facts relied on and the provisions of the Fair Work Act relevant to the claim)
Attach an extra sheet if required		

Part H – Remedy sought	
26. What are you asking the Court for?		Injunction
Please specify on an attached sheet the terms of the injunction or injunctions sought.
	Compensation
Please give details on an attached sheet of how much compensation the employee is claiming and how the amount has been calculated (eg loss of income).
	Reinstatement
	Pecuniary penalty
	Other
Please give details on an attached sheet	
27. To whom should any compensation, pecuniary penalty or other amount ordered be paid?		Compensation:  ........................................
	Pecuniary penalty:  ........................................
	Other:  ........................................

Part I – Required documents	
28. A certificate issued by the Fair Work Commission under s 777 of the Fair Work Act must accompany your application and claim, unless you are seeking an injunction as to all or part of your claim		Copy of certificate attached
	Copy of certificate not attached

Signature of applicant, lawyer or authorised representative
	
Signed by (print name) .......................................................
	the applicant
	lawyer for the applicant
	authorised representative of the applicant
Date:	............/............/...........	

Form approved by the Chief Judge pursuant to subrule 2.04(1) for the purpose of subrule 30.05(b)
FW_ClaimForm3_0921V1