Reconsideration form

You may use this form to apply for a reconsideration if you are dissatisfied with a decision, determination, direction or notice made by QLeave.

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Step 1 of 3 - Your Details

Worker/Employer/Levy Payer number (if known)

Title

-- Please Select --MrMrsMsMiss

First Name *

Last Name *

Company name (if applicable)

Phone *

Email *

Address *

Suburb *

State

ACTNSWNTQLDSATASVICWA

Postcode *

Do you have a different mailing address?

• Yes
• No

Postal address

Suburb

State

ACTNSWNTQLDSATASVICWA

Postcode

I certify that the information provided is true and correct to the best of my knowledge. *

• Yes
• No

Step 2 of 3 - Decision Summary

What was the decision about?

If you have a copy of the decision (for example a letter, notice or other document) please attach it to your application.

Date of the decision

Who made the decision?

Step 3 of 3 - Reason for application

Why are you requesting a reconsideration? *

Please attach any supporting documents

Addition supporting document 01

Addition supporting document 02

Submit

Date *