Prescribed Form 5 – Request for Disciplinary Tribunal Hearing

Charged Party

Fixture Details

DD slash MM slash YYYY

Offence(s) Being Challenged

DD slash MM slash YYYY

Contact Details for Disciplinary Tribunal Hearing


In lodging this request, the Club acknowledges that:(Required)

A request for a Tribunal hearing that does not meet all of the above requirements will not be accepted under any circumstances.

Payment of the Tribunal Fee

Payment is to be made directly into Football West’s bank account: BSB: 306-089 A/C: 2766668. Use “Club Name & Disciplinary Tribunal” as the payment reference. Tribunal Fees: Senior Competitions – $550 Junior Competitions – $330
Max. file size: 128 MB.


This form along with proof of payment must be lodged by either the President or Secretary of the club. A form lodged by any other person will not be accepted unless: a) the club can demonstrate exceptional circumstances exist and approval has been received in writing by Football West; b) the charged party is not an associate of any club; or c) if it bears the name and signature of the President or Secretary below.
Lodged By(Required)