Prescribed Form 09

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Member Details

Full Name*

Decision of the Disciplinary Committee

DD slash MM slash YYYY
DD slash MM slash YYYY
Max. file size: 15 MB.
Max. file size: 15 MB.


Does the Appeals Tribunal have jurisdiction to hear this matter?
The jurisdiction of the Appeals Tribunal is set out in section 10.1 of the Football NSW Grievance and Disciplinary Regulations (Regulations). The Appeals Tribunal will only hear an appeal iif it relates to a decision that was made by the Disciplinary Committee pursuant to section 8.3 of the Regulations (appealing a decision of the DC (Red Card Offences)).
Further, the Participant must satisfy one or more grounds of appeal set out in section 10.2 of the Regulations.
Please state the grounds you wish to rely on

Affected Party

Please provide relevant facts and legal arguments that relate to each of the grounds of appeal that you wish to rely on.*
  • 1. Please submit this form within 7 working days of the issuance of the decision of the DC to the Club by Football NSW.
  • 2. Please lodge a fee of $750 together with this Notice. Payment can be made by cheque or direct debit into Football NSW’s bank account. Bank: National Aust Bank Ltd, Account Name: Football NSW Limited, BSB: 082-356, Account Number: 14-055-1058. Please file receipt of payment into this account with the Tribunal Administrator at
  • 3. Participants should read and consider sections 8, 10 and 13 of the Regulations prior to signing and lodging this Notice to Football NSW.
  • 4. If Football NSW does not receive a properly completed Notice by the time specified in paragraph 1 together with the $750 fee, you are deemed to have waived your right to appeal the decision of the DC.
  • 5. Capitalised words used in this document are defined in the Regulations.
  • Submission

    Your name*
    Digital Signature*