(Rule 12(6))

Ph No:

Fax No:

E-mail address:

COPYRIGHT ACT 1999

Reference Number ________________

Application Number ________________

Re: In The Matter of ________________

• 1.In exercise of the powers conferred upon it under section ________ of the Act, and after taking into account all the relevant factors surrounding the application or reference, and having heard submissions from every party to the application or reference, the Tribunal makes this Order—

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• 2.The grounds on which the Order is made are:________________

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Dated at this day of 20 .

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Chairperson of the Tribunal