Form 5 Reference of prohibition notice for review

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Form 5 - Reference of prohibition notice for review

[Regulation 2.8(2)]

Occupational Safety and Health Act 1984 section 51
WorkSafe Western Australia Commissioner

Mason Bird Building, Level 1 303 Sevenoaks St CANNINGTON WA 6107

Postal: Locked Bag 14, Cloisters Square PERTH WA 6850

Phone: (08) 6251 2307

Fax: (08) 6251 2832


Take notice that I,


(print name of person referring notice for review)

refer prohibition notice number


issued by





(date notice was issued)

to you for review.

The prohibition notice relates to the workplace at:






Activity prohibited:

I request the review on the following grounds:

Please respond to this question in the space provided on page two

Signature of person referring notice for review:


NOTE: A reference of a prohibition notice for review must be made to the Commissioner within 7 days of the issue of the notice or such further time as may be allowed by the Commissioner [section 51(2)(b) of the Act].

Please attach a copy of the prohibition notice to this form

Position/Job Title of person requesting review:






Full name of the person to whom the notice was issued, including if applicable the Pty Ltd, Limited etc., and any Registered Business name and number


Company ACN:


I request the review because: (use a separate sheet if more space is required and attach any supporting documentation)

(Must provide reason)


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