Application to Authority Section 158, Employment Relations Act 2000

rr 5, 6

Form 1

Application to Authority

Section 158, Employment Relations Act 2000

Between
Full name of Applicant …………………………………………………………………………………………

Address …………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………..

Telephone number……………………………………………………………………………………………….

Email address ……………………………………………………………………………………………………
And
Full name of Respondent……………………………………………………………………………………….

Address …………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………..

Telephone number……………………………………………………………………………….....................

Email address …………………………………………………………………………………………………….

To the Employment Relations Authority

and

To the respondent

Statement of problem or matter

1 The problem or matter that I wish the Authority to resolve is: [state details fully, fairly, and clearly].

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

2 The facts that have given rise to the problem or matter are: [state details fully, fairly, and clearly].
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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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3 I would like the problem or matter to be resolved in the following way: [state details fully, fairly, and clearly].*

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
*Please include reference to any specific remedy (being a remedy under any enactment or rule of law) that you are seeking. If the applicant is an employee who is seeking, by this application, an order, under section 127(1) of the Employment Relations Act 2000, for the employee’s interim reinstatement, the applicant must, at the time of lodging this application, file a signed undertaking in form 2.

4 I attach a copy of the applicable employment agreement and the following documents that I think are relevant to the problem or matter:*

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

*List all the documents or letters that you wish to rely on or documents required under other legislation, etc.

Mediation
5 Have the parties tried to resolve this problem or matter by using mediation services provided by the Ministry of Business, Innovation, and Employment? Yes/No*

*Select one.

If the answer to this question is “Yes”, please provide the date or dates of the mediation:
………………………………………………………………………………………………
6 Have the parties tried to resolve this problem or matter by using mediation services provided by someone other than the Ministry of Business, Innovation, and Employment? Yes/No*

*Select one.

7 If you, the applicant, have answered “No” to both the question in paragraph 5 and the question in paragraph 6, please indicate why you have not used mediation services to try to resolve the problem or matter: [state details fully but concisely].
………………………………………………………………………………………………………………………………………………………………………………………………
8 Have you, the applicant, taken any other steps of any kind to resolve the problem or matter? Yes/No*

*Select one.

If the answer to this question is “Yes”, specify the other steps taken: [state details fully but concisely].
………………………………………………………………………………………………………………………………………………………………………………………………

Prescribed fee
9 This application is accompanied by the prescribed fee.

Address for service
10 This application is lodged by [full name of applicant] / [name of representative] *Select one …………………..………………………………………………………….on behalf of [full name of applicant]*………………………………………………………………………………………………

.
11 The applicant’s address for service is ......................................................................

………………………………………………………………………………………………..

Telephone number is ……………………………………….. fax number for service is ……………………………., document exchange number for service is………………. and email address for service is* ...............................................................................

*Although a full address must always be supplied, the supply of a telephone number and a fax number, a document exchange number, or an email address is optional.

Date: ……………………………………………

Signature:……………………………………….

(applicant)

Notice to respondent

1. 
   If you intend to respond to this application, you must, within 14 days after the date of the service of this application on you, lodge 2 copies of a statement in reply with an officer of the Employment Relations Authority at [place]. ……………………………….
   

2. 
   The term days does not include any day in the period beginning with 25 December in any year and ending with 5 January in the following year.
   

3. 
   You will be notified of the place, date, and time at which the Authority will conduct any investigation meeting in respect of this application.
   

Date: ………………………………………………

Signature:………………………………………….

(Officer of the Employment Relations Authority)

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