Prescribed Form 11

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Applicant Details

Type of Application

Is your application in reference to a “claim” or “complaint”?*
Pursuant to section 8.3 of the Football NSW Grievance and Disciplinary Regulations (Regulations), a “Claim” means a claim or disagreement by, against or between Members and “Complaint” involves the allegation that a Member’s conduct is unethical and/or in breach of FFA Rules and Regulations, Football NSW Rules and Regulations or a Member Association’s rules and regulations

Respondent Details

Affected Parties

Your application for relief may have consequences for other parties. Football NSW is concerned to ensure that any Affected Parties (including Football NSW) are aware of your application and are provided with an opportunity to be heard.
Is there another party potentially directly affected by your appeal?*


Do you wish to be represented by a support person of the Club?*
Do you wish to be represented by a lawyer?*


Does the General Purpose Tribunal have jurisdiction to hear this matter?*
Football NSW’s jurisdiction in relation to Grievances is set out in section 8.3 of the Regulations. Football NSW will only hear a Claim or Complaint in the following circumstances:
(a) The Applicant and Respondent are Members of Football NSW (as defined in Schedule 1 of the Regulations); and
(b) The Applicant and Respondent have exhausted the processes set out in section 8.3 of the Regulations.
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Details of the Grievance

You must include a clear statement of the issues you are submitting.
Max. file size: 15 MB.
1. Please submit this form within 14 working days after the dispatch of the notice referred to in section 9.3(c).
2. Please lodge a fee of $500 together with this Form. 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. Members should read and consider sections 9, 12 and 13 of the Regulations prior to signing and lodging this Form toFootball NSW.
4. Pursuant to section 9.3 of the Regulations, your Claim or Complaint will be dealt with by mediation (section 12 of the Regulations) in the first instance unless Football NSW believes that the claim or complaint should be referred to a GPT.
5. If Football NSW does not receive a properly completed Form by the time specified in paragraph 1 together with the $500 fee, you waive your right to have the matter heard at Football NSW.
6. Capitalised words used in this document are defined in the Regulations.


Digital Signature
I certify that the information entered above is true and correct and was entered by myself.
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