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 *

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?

Please attach a copy of the decision (for example a letter, email, notice or other document) 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 * Supporting documents must be attached. For example, payslips, payment summaries, invoices, or any other documents that support your request.
Please note, we don't accept notices of assessment as evidence for reconsideration requests.

Submit

Date *