DIY – UFD form 1Information about you2Information about your employer3Remedy Title Mr Mrs Ms Other Other please specify First Name* Surname* Street address* Suburb* State or Territory*ACTNSWVictoriaQueenslandWASANTTasmaniaPostcode* Mobile number* Email* Do you need an interpreter? Yes No specify language Do you need any special assistance at the hearing or conference?*eg a hearing loop Yes No Please specify the assistance required Do you have a representative?* Yes No Representative's Name Representative: Firm, union or company Representative: Postal adress (street) Representative: Suburb Representative: State or TerritoryACTNSWVictoriaQueenslandWASANTTasmaniaRepresentative: Postcode Representative: Phone number Representative: Email address All questions in this section relate to the respondent (the employer). These are the details of the employer that dismissed you.Legal name of employer*Provide the legal name of the employer that dismissed you. Your payslips or employment contract should give the legal name of employer. Contact person*Note that the Commission will send a copy of your application to the contact person you name below. ABN* Employer's postal address (street)* Employer's suburb* Employer's State or Territory*ACTNSWVictoriaQueenslandWASANTTasmaniaEmployer's Postcode* Employer's Phone Number* Employer's email address* Your employmentWhat date did you begin working for the employer?* DD slash MM slash YYYY Primary workplace/worksite street address*Where did you work for the employer? Suburb (workplace)* State or Territory (workplace)*ACTNSWVictoriaQueenslandWASANTTasmaniaPostcode (workplace)* What date were you notified of your dismissal?* DD slash MM slash YYYY What date did your dismissal take effect?* DD slash MM slash YYYY Are you making this application within 21 calendar days of your dismissal taking effect?* Yes No Whether to accept application out of timeThe commission may extend the time period for lodgement if it is satisfied that there were exceptional circumstances for not lodging within 21 days of the dismissal. If you are late filing because you did not know about the 21 day timeframe an extension will not be granted, ignorance of the law is not a defence. However, if any of the following apply an extension might be granted: I have been diagnosed with a physical or psychological illness or injury that has prevented me from commencing my application [upload medical evidence to attach to the form] The date of dismissal was not clearly communicated to me, I was not clear on when the dismissal was effective I instructed a representative to assist me with the application and they made an error Have you made another claim regarding your dismissal?*Warning! The Commission cannot consider your unfair dismissal application if you have made another claim in relation to the dismissal, for example if you have made a general protections application in relation to the dismissal or a complaint to the Human Rights Commission in relation to the dismissal. Yes No What outcome are you seeking by lodging this application?*Note: Copy and paste one of the two options listed. * I want my job back with continuity of service and lost wages from the date of my dismissal. * I want compensation. What were the reasons for the dismissal, if any, given by the employer?*Note: Only include the reason given in the dismissal meeting or the letter of dismissal. If you were made redundant insert redundancy, if you were forced to resign insert - forced resignation. If you weren't given a reason insert - no reason provided. Why was the dismissal unfair?*Describe why you say the dismissal was unfair. The dismissal may be unfair if any of the following are true - (copy and paste any that apply to you) * My dismissal was not a case of genuine redundancy - the job I am doing is still required to be performed. * My dismissal was not a case of genuine redundancy – I was not consulted about the changes to my job. * My dismissal was not a case of genuine redundancy – I was not offered available redeployment opportunities. * I was forced to resign due to conduct of my employer eg. I was threatened with performance management if I did not resign or I was experiencing workplace bullying * There was no valid reason for my dismissal eg. I did not do the things I have been accused of * I have the capacity to do the job required by my employer * I was not notified of the reason for my dismissal * I was not given an opportunity to respond to the reason for my dismissal before the decision was made * I was not permitted to have a support person * I had no prior warnings * My employer is not a small business and has human resources support, this should not have happened * Other employees have engaged in the same conduct and have not been dismissed * I am the sole/main earner * It is likely to take me a long time to find other employment because eg. I am pregnant, I am over 55, I live in a remote area, I am subject to a post-employment restraint * I have an unblemished employment record * I was dismissed without notice or payment in lieu of notice. HiddenConsent to contact by researchers Yes No Full Name*We will use this in place of your signature and to identify you as the person the Commission should contact to pay the filing fee by credit card (currently $73.20). A Commission officer will contact you by telephone within 3 business days from the date of lodgment. HiddenCapacity Position HiddenDate DD slash MM slash YYYY HiddenPayment options Paying by credit card HiddenPayer details You HiddenPostal address CAPTCHA Δ