IN THE FEDERAL CIRCUIT AND	File number: ....................................
FAMILY COURT OF AUSTRALIA
REGISTRY: ........................................................
......................................................................
Applicant
.....................................................................
Respondent
Repeat as necessary for additional parties
Form 2
Fair Work Division
Rule 30.04(b)
	Claim under the Fair Work Act 2009 alleging dismissal in contravention of a general protection	

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 dismissal?		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 it?		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 – Contravention(s) alleged	
24. What are the grounds for the claim that the employee was dismissed in contravention of a general protection?
(Set out in numbered paragraphs the facts relied on and the provisions of the Fair Work Act relevant to the claim)
If relying on s.340 specify the ‘workplace right’ claimed.
If relying on s.351 specify the attribute in s.351(1)
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.368 of the Fair Work Act must accompany your application and 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 30.04(b)
FW_ClaimForm2_0921V2