Notice of Election of Hearing Form

A filling fee of $250 must be paid at the time of lodging this form. A copy of this form must also be provided to the other party to the dispute.

Horse Description

Horse Name *

Foal Year of Birth (yyyy) *

Microchip Number *

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Trainer Details

Date of Birth

Surname of Trainer *

Given Names of Trainer *

Postal Address *

Postal Address

City

State

Postcode

Country

Email Address *

Mobile *

Daytime Phone *

Owner Details

Date of Birth

Surname *

Given Names *

Postal Address *

Postal Address

City

State

Postcode

Country

Email Address *

Mobile *

Daytime Phone

Claimed/Disputed Invoice #1

Please clearly indicate either the full amount of the invoice being claimed or disputed, or if the full amount is not being claimed or is not in dispute, please clearly indicate the amount and items of the invoice being claimed or disputed.

Invoice *

Full Invoice

Part Invoice

Date of Invoice *

Date Invoice Received *

(if different to date of invoice)

Disputed Amount *

Brief Description of Nature of Dispute *

For an Invoice which is partly in dispute, please indicate clearly the part of the invoice in dispute and whether the part not in dispute has been paid to the Trainer

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Declaration

DECLARATION - IMPORTANT - MUST SIGN *

I confirm that I am lodging this Notice of Election of Hearing Form within 14 days from when I issued / was issued with the Dispute Notice in relation to the invoices identified in this form.

I confirm that the information in this form is true and correct.

Signature *

Clear

Date *

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