Reconsideration/Internal Review form

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

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Step 1 of 3 - Your Details

Select your industry

-- Please Select --Building and Construction IndustryContract Cleaning IndustryCommunity Services Industry

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

Step 2 of 3 - Issue/decision summary

What is your reconsideration request about? *

Date of the decision (if known)

Select the issue/decision this reconsideration is about *

--Select--Cancellation of worker registration - no service recorded for four yearsCancellation of registration - otherLong service leave or reimbursement claim refusedBackdating of worker or employer registrationQLeave leviesEligibility of serviceRemoval of serviceOther

Please provide further details about the decision *

How were you made aware of this decision? *

• I received an email
• I received a letter
• I was told over the phone
• I received an SMS
• Other

If available, please attach a copy of the notice For example, a copy of the letter or email you received.

Date of the notice (if received)

Step 3 of 3 - Reason for application

Why are you requesting a reconsideration? *

--Select--Service is not recorded on QLeave's registerEmployer has not reported my serviceStill working in the industryI have an unclaimed long service leave entitlementIncorrect levies charged or paidLevy exemptionLevy - otherI am a working directorI am an eligible workerOther

Please provide further information to support your reconsideration request *

Please attach any supporting documents which you believe support your request * 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.
If you're making this reconsideration because your registration was cancelled, please attach documentation that shows that you were performing eligible work in the industry during the four year gap in your service record.

Have you performed eligible work in another Australian state or territory?

• Yes
• No

Select the state or territory you have worked in

If you've recorded service with multiple interstate schemes, please select all that apply.

• New South Wales
• Victoria
• South Australia
• Western Australia
• Tasmania
• Northern Territory
• Australian Capital Territory

Please attach a long service leave statement showing service recorded interstate You can get copies of your interstate long service leave statements by contacting the relevant interstate scheme. Click here to find the contact details for each interstate scheme.

Submit

Date *

I understand that failure to attach supporting documentation may affect the outcome of this reconsideration application *

• Yes

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

• Yes