ࡱ> g bjbjVV ;r<r<0K  dddddxxx8Tx#p88L"""""""$3%'p"d^"dd}#!!!!!! dd"!!"!!!!!!8uX!"#0#!U(rU(!U(d!|!!dwN""9 #U(  *:  Complaint Form (Version 2/09) Part A 鱨վ you (the complainant) Enquiry reference no:  Name: Mr/Mrs/Miss/Ms: Address: .. Post code: . Contact numbers: Home: Business:. Fax: Mobile: TTY: Email: . Only fill out this box if you are complaining on behalf of someone elseName of that person: What is your relationship to that person? Only fill out this box if someone is assisting you with the complaint for example a solicitor or union representativeName of representative: Organisation: ... Postal address: .. Contact numbers: Home: Business: Fax: Mobile: .... TTY: Email:  **If you need help to fill in this form please contact one of our Complaint Information Officers on 1300 656 419 (local call charge) or (02) 9284 9600. Part B Your complaint  Who are you complaining about? (the respondent) 1. Name/organisation:............................................................................................................................. Address:.................................................................................................................................................. .............................................................................................................................. Post code:............... Contact numbers: Home:............................Business:............................Fax:.... Mobile:................................TTY:.......................................Email:......................................................... What is this persons/organisations relationship to you?........................................................ ................................................................................................................................................................... ................................................................................................................................................................... 2. Name/organisation:............................................................................................................................. Address:.................................................................................................................................................. ..........................................................................................................Post code:.................................... Contact numbers: Home:........................... Business:........................... Fax:.............................. Mobile:.............................. TTY:............................... Email:...................................... What is this persons/organisations relationship to you?........................................................ ................................................................................................................................................................... ................................................................................................................................................................... If you are complaining about more than two people or organisations, please provide this additional information on an extra page. Why are you complaining to the Commission? I am complaining because I believe: r I have been discriminated against because of my sex (incl pregnancy, marital status, family responsibilities); r I have been sexually harassed; r I have been discriminated against because of my race; (incl descent, national / ethnic origin, colour, immigrant status, racial hatred); r I have been discriminated against because I have a disability (incl physical, intellectual, psychiatric, learning, work related, medical condition, disease such as cancer or HIV, associates and carers of a person with a disability); r I have been discriminated against because of my age; r My human rights have been breached by a federal government agency; or r I have been discriminated against in my employment because of my (please tick which one): m sexual preference m trade union activity m criminal record m religious belief m political opinion r I have been treated unfairly for another reason. Please state the reason: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & . When did this happen? (Day/month/year) What happened? Describe the events that you want to complain about. We need to know what you say happened, where it happened and who did it. Please give us all the dates and other details that you can remember. If you are complaining about employment, please tell us when you commenced employment, your job title and whether you are still employed. Signature: .. Date: Part C Further information  Supporting evidence Please attach copies of any documents that may help us investigate your complaint (for example, letters, pay slips, doctors certificates or references). If you cannot do this, please tell us about the documents or other evidence and how this evidence can be obtained. How has this affected you? Please tell us how what you are complaining about has affected you? What outcome are you seeking? Have you made a complaint about this to another agency? (For example a state anti-discrimination or equal opportunity agency, a workers compensation agency, an ombudsman or an industrial relations commission.) If so, you must provide details of the complaint, the agency it was made to and any outcome. 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(For example through an internal complaint process or your trade union.) If so, please give details: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Remember n to sign and date page 6 of this document;ǐȐ7a)$ 86n J $\8!n#%7$8$H$a$gdhX&$$ ) 6n J $\(7$8$H$a$gdh"$ ) 6n J $\7$8$H$a$gdhX&"$ ) 6n J $\7$8$H$a$gdh $H]Ha$gdh ёґjlΒВ24 '$ ,6n J $\997$8$H$a$gdhX&$$ ) 6n J $\97$8$H$a$gdhX& $H]Ha$gdh"$ ) 6n J $\7$8$H$a$gdh ^`ԜTVZ\`bfhlnprtvxǶǶtlhlhlhlhd`d`d`h h1hhgHjhgHUh;;CJ OJQJ^JaJ h; 7hhX&CJ OJQJ^JaJ &h; 7hhX&5CJ"OJQJ\^JaJ"Uh; 7hhX&OJQJ^J h; 7hhX&CJOJQJ^JaJ h; 7hhX&CJOJQJ^JaJ&h; 7hhX&5CJOJQJ\^JaJ&h; 7hhX&5CJ,OJQJ\^JaJ, and n attach copies of any relevant documents. 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