Internal Review application form

Effective 30 January 2024
QLE/FMS/FMA Form 1v1

If you are dissatisfied with an original decision, determination, direction or notice made by QLeave or the accuracy of an entry made in the register, you may use this form to apply for an internal review. Please note that timeframes may apply. Refer to s87 of the Building and Construction Industry (Portable Long Service Leave) Act 1991, s91 of the Contract Cleaning Industry (Portable Long Service Leave) Act 2005, s92 of the Community Services Industry (Portable Long Service Leave) Act 2020 for further information.

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Step 1 of 4 - Applicant Details

Select your industry

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

Worker/Employer/Levy Payer number *

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 4 - Details of Original QLeave Decision

Select the decision category this request relates to *

--Select--Backdating worker/employer registration dateCancellation of worker/employer registration Worker eligibilityCalculation of levy payableWorker/employer claim for entitlementApproval/refusal of worker service creditsOther

Date of the decision (if known)

How were you made aware of the original decision?

--Select--I received an emailI received a letterI was advised over the phoneOther

Date you were made aware of the original decision

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

Step 3 of 4 - Reason for internal review application

Please outline why you are dissatisfied or aggrieved with QLeave's original decision and what outcome you are seeking in submitting the application. * Any documents supporting your application must be provided and attached to this application.

Please attach any supporting documents which you believe support your request * For example, payment summaries, individual tax returns, interstate service statements, invoices or any other documents that support this application.
If you’re submitting this application because your worker registration was cancelled, your documentation should demonstrate that your registration should have been credited with service during the four-year period prior to the cancellation decision.

Have you had service credits recorded, or received an annual notice of service (long service leave statement), with 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.

Step 4 of 4 - Declaration

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

• Yes
• No

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

• Yes
• No

QLeave is collecting the information on this form for the purposes of administering the Building and Construction Industry (Portable Long Service Leave) Act 1991, the Contract Cleaning Industry (Portable Long Service Leave) Act 2005, and the Community Services Industry (Portable Long Service Leave) Act 2020, as required by the applicable Act. QLeave may give some or all of this information to various other Government departments or agencies as required or permitted by law.