form styling test

Further information about your circumstances

Instructions for using this form

- Please fill in as much information as you can. It's okay if you don't know the answers to all these questions. However, the more information you give us, the easier it is for us to help you.
- Some questions are marked "required" which means you must try to answer them before you can send this form.
- If you don't understand the form or are having trouble filling it out, you can call us on (08) 6148 3636 to request a team member call you back to go through the form with you over the phone instead.

Privacy statement

You should have read our privacy statement when you made your online enquiry. If you did not, you can access it below. It's important that read the privacy statement before providing your details to us. Click here to read the privacy statement. We do not provide advice by email. If you have a disability that prevents you from speaking to us on the phone, please let us know in the form below.

I have read and understood the privacy statement and all the information above

If you cannot read or don't understand the privacy statement you should call our Advice Line instead. If you are eligible to receive legal advice, a member of staff can explain the privacy statement to you.

Click here for information on how to call our Advice Line.

Personal details

Family name(required)

First name(s)(required)

Enter your full name. We are unable to provide advice if you do not give your full name.

Telephone number(required)

Please provide a telephone number we can call you on to provide assistance. It is important that this number is safe for us to contact. Please avoid providing a work number.

Second telephone number (if you have a second number)

We will only call this number if we can't get through to you on the first number you have provided above.

Email address(required)

Please provide an email address that is safe for us to contact and that you check regularly.

Address Line 1(required)

Please provide an address that is safe for us to contact if we cannot contact you by telephone or email.

Address Line 2

Suburb(required)

Postcode(required)

What is your date of birth?(required)

If other, please describe:

Do you identify as Aboriginal or Torres Strait Islander?(required)

Yes

Prefer not to disclose

Is English the main language you speak at home?(required)

Yes

What is the main language you speak at home?

Will you require an interpreter when we call you?

Yes

What is your residency status? (required)

I am an Australian citizen

I am an Australian permanent resident

I am in Australia on a temporary visa

Other

What is your nationality?

Were you born in Australia?

Yes

What is your country of birth / origin?

What year did you arrive in Australia?

Do you have any disabilities?(required)

Yes

Prefer not to disclose

What is your disability?

Do you have any problems reading or writing English?(required)

Yes

Prefer not to disclose

If yes, please describe:

What was your income in the last 12 months before tax (gross)? (required)

If you don't know the exact amount you've earned in the last 12 months, please make your best estimate.

What is your current income?

If your current income is different than your income in the last 12 months, please provide your current income here.

What is your main income source?

Wages / salary from job

Centrelink benefits

Other

If other, please describe:

Does your partner earn an income that is shared within your household? (required)

Yes

What was your partner's income in the last 12 months before tax (gross)?(required)

If you don't know the exact amount your partner earned in the last 12 months, please make your best estimate.

Do you have any dependants?(required)

Yes

A dependant is a child or another person who relies on your financial support.

How many dependant children do you have? (required)

How many other dependants do you have? (required)

Employer details

What is your employer's ABN?

An "ABN" is an Australian Business Number. You can normally find your employer's ABN on your payslips or group certificate. We will still accept your application if you don't know your employer's ABN, however you should make an effort to find it as we may not be able to provide accurate advice without it. If your issue is with a previous employer, enter that employer's ABN, not your current employer.

Did you receive pay slips from the employer?(required)

Yes

I don't know

What is the trading or business name of your employer?

If your issue is to do with a previous employer - enter the name of your previous employer, not your current employer.

What type of employer do you work for?

Which of the following best describes the industry your employer works in?

How many employees does your employer have?

Employment details

What is (or was) your salary or hourly rate with your employer?

How many hours (on average) did you work or do you work per week?

What is (or was) your position or job title with your employer?

Did you sign a written employment contract or letter of offer with your employer?

Yes

Unsure

Do you know if your employment is covered by an award or registered agreement (e.g. enterprise agreement)?

Yes - award

Yes - registered agreement

No - I am not covered by an award or enterprise agreement

I don't know

If you don't know what an award or registered agreement is, please select I don't know and we may be able to help you with this.

What is the name of the award?

What is the name of the agreement?

Which of the following best describes the type of worker that you are (or were) while working with your employer

What was the date that you first started working with your employer?(required)

If you are not sure of the exact date, please provide your best estimate (or a month and year).

Please provide details

When is / was your last day of work?

If you are not sure of the exact date, give us your best estimate.

When were you dismissed / forced to resign?

If you are not sure of the exact date, give us your best estimate.

Problem or issue details

Are there any other people you are in conflict with in relation to your issue at work? For example, boss, colleague, HR person?(required)

Enter the full names of any one else directly involved in the issue or issues you are having.

Brief description of the problem or issue(required)

Please briefly outline the problem or issue you are having at work. Your entry is limited to approximately 300 words. We will be able to take more complete instructions from you when we call you.

What questions do you have for us?(required)

Please write down the questions you want answered

What is your ideal outcome?

Contact time

If there is a time, or times that you are not available for an employment law advice call, please tick the boxes below. If you have limited availability, you may have to wait longer for advice.

Please note we may be calling from a blocked number with no caller ID. Please make your best efforts to answer your phone over the coming period. If we cannot successfully call you after 3 attempts, you will receive an email requesting that you resubmit your online enquiry.

If you cannot, or would prefer not to accept a phone call because of a hearing impairment or other disability, please check the box at the bottom of the list.

Unavailable days / times

Please select all days / times you are NOT available for an employment law advice call:

Referral pathway

Please provide details

I declare that everything in this form is true and correct. I understand that I may be asked to provide evidence verifying the information I have provided, and agree to provide such evidence if asked.

I agree with the statement above

Providing false information can make it difficult for us to provide accurate advice

This field should be left blank