Form A95
APPLICATION FOR REVIEW OR
APPEAL (SAET ACT)
Case Number
(SAET use only)
About this form

This is the approved form for internal review of a matter, or an appeal of a matter, to the South Australian
Employment Tribunal.

Submitting an incomplete form (including any relevant supporting documents) may result in delays.
PARTIES
Applicant
Respondent
Other Party
APPLICATION TYPE
☐ An application for a review of a decision of a a member of the Tribunal who is not a Presidential member [s66]
☐ An appeal against a decision of a single Presidential member [s67]
APPLICANT
☐ Mr
Title
☐ Mrs
First name
☐ Miss
☐ Ms
☐ Other (specify):
Last name
Email
Is anyone representing
you?
☐ No
☐ Yes. Please specify:
Representative detail (if required)
Organisation
Contact First name
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
Postcode
State
Country
THE DECISION UNDER REVIEW OR APPEAL
Name of SAET member(s)
Date of decision
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
Version as at 1 July 2017
1/2
South Australian Employment Tribunal
Form A95 – Application for review or appeal (SAET Act)
Decision number (if applicable)
Do you require an extension of
time within which to appeal?
☐ No
☐ Yes. Please specify the grounds:
GROUNDS
Set out details of the Tribunal’s decision, or the relevant part of the Tribunal’s decision, to be reviewed or
appealed, and your grounds for seeking the review or appeal:
ORDERS SOUGHT
Set out orders sought in successively numbered paragraphs.
A request for a stay of operation, where appropriate, may be included in this application. Alternatively the
application may be made separately by lodging an Application for Directions.
1.
…
LODGING YOUR COMPLETED FORM
The person lodging this form must send a copy to all other party/ies.
Name of person lodging
Signature
Date
Please lodge this form, together with any accompanying documents, with the South Australian Employment
Tribunal:
Email: [email protected]
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
Version as at 1 July 2017
2/2