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Schedule 3.3Forms relating to entry to premises Form4Affected member certificate

Form4—Affected member certificate

(regulation 3.29)

Fair Work Regulations 2009, regulation 3.29


This certificate is issued to [name of organisation].

Section 520 of the Fair Work Act 2009 authorises Fair Work Commission to issue an affected member certificate if a permit holder seeks to enter premises for the purpose of investigating contraventions, or suspected contraventions, of the Fair Work Act 2009, or a term of a fair work instrument.

For section 520 of the Fair Work Act 2009, Fair Work Commission is satisfied that:

* a member of the organisation performs work on the premises below; and

* the organisation is entitled to represent the industrial interests of the member; and

* a suspected contravention of the Fair Work Act 2009, or a term of a fair work instrument, relates to, or affects, that member.

For this certificate:

(a) The premises to which it relates are:

[name and address of premises]

(b) The suspected contravention or contraventions to which it relates are:

[particulars of suspected contravention or contraventions]



Delegate of Fair Work Commission


Fair Work Regulations 2009

Compilation No. 36

Compilation date: 11/09/2021

Registered: 19/10/2021

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