Cooperation agreement eligibility form

Use this form to request to enter a cooperation agreement with us.

When to use this form

Use this form if you want us to consider your eligibility to enter into a cooperation agreement because you've engaged in conduct that may amount to a criminal underpayment offence.

Examples of who can make a request are:

an employer
a business, or
an individual.

Learn more about cooperation agreements and eligibility at Cooperation agreements.

You're encouraged to seek independent legal advice before voluntarily reporting to us that you may have committed an offence, including in relation to the information you may be providing in this form.

Penalties for false or misleading information or documents

You may be liable to a civil penalty under the Fair Work Act if you knowingly or recklessly give false or misleading information or produce false or misleading documents to us (the Fair Work Ombudsman) while completing this form. It's also a serious offence under the Criminal Code Act 1995.

When to use our other forms

This form is to request us to consider your eligibility to enter into a cooperation agreement with us.

Use our other forms for different workplace issues, such as:

asking our help with a workplace problem – use our online enquiry form
reporting a workplace issue anonymously – make an anonymous tip-off
asking for workplace advice as a small business owner – lodge an enquiry with the Employer Advisory Service.

How to complete this form

It will take between 10 to 15 minutes to complete our form.

We'll ask you to answer questions about your situation and the conduct that may amount to the criminal underpayment offence.

If you decide not to continue with your request at any time, simply use the Clear Form button or close the tab or window. Any information you've already entered will be deleted.

Mandatory field(s) marked with (required) *

Acknowledge you have read and understood the above information. (required)

Personal or entity information

In what capacity are you submitting this form? (required)

Other/Unsure (required)

*

Your name (required)

*

Your phone number (required)

*

Your email address (required)

**

Information regarding employer

Legal entity name (required)

*

Trading name (required)

*

Australian Business Number (ABN) / Australian Company Number (ACN) (required)

*

Industry (required)

Sub industry (required)

Details of potential offence

Describe the potential offence (required)

*

Potential offence start date

*

Potential offence end date

*

Describe the conduct that resulted in the underpayments (required)

*

Have the impacted employees been informed of the underpayment(s)?

Have the impacted employee(s) been back-paid?

Declaration

The information I have provided is true and correct to the best of my knowledge and belief. I understand that giving false or misleading information is a serious offence. (required)

Declared by (required)

*

What happens after you lodge this form

We'll review your submission and contact you within 5 business days. For further information about how we use your information, visit Privacy.

Automatic translation

Language help

Popular searches

FWO Search