43
Rules of the Sports Tribunal of New Zealand
Application for Provisional Suspension in Anti-Doping
Rule Violation Matter
1. Details of the Applicant
Name
Postal Address
Contact Person for this application
Name
Position
Telephone (Wk) Mobile
Facsimile (Wk)
Email
2. Details of the Athlete
Please provide the last known contact details of the person against whom you allege may have or has
committed an Anti-Doping Rule Violation (“the Athlete”).
Name
Postal Address
Telephone (Wk) (Hm)
Facsimile (Wk) Mobile
Email
3. Details of Representative
Please insert the details of your legal representative or other person, if any, who will be representing the
Applicant in these Proceedings.
Name of Representative
Firm/Company
Postal Address
Contact Person for this application
Name
Position
Telephone (Wk) Mobile
Facsimile (Wk)
Email
FORM 6
TITLE FIRST NAME SURNAME
STREET SUBURB
CITY
POSTCODE
TITLE FIRST NAME SURNAME
STREET SUBURB
CITY
POSTCODE
TITLE FIRST NAME SURNAME
STREET SUBURB
CITY
POSTCODE
TITLE FIRST NAME SURNAME
Rules of the Sports Tribunal of New Zealand
44
4. Jurisdiction
Provide jurisdiction for provisional suspension.
5. Alleged Anti-Doping Violation
(a) Give details of the alleged anti-doping violation.
(b) Give details of the article or rule in the WADA Code, Sports Anti-Doping Rules or other relevant
constitutional or regulatory provision which the Athlete has allegedly infringed.
(c) Summarise the reasons which apply to provisional suspension.
6. Notifi cation of Adverse Analytical Finding attached
Please provide with this Application a copy of the Notifi cation of the Adverse Analytical Finding. Please
ensure all relevant documents received such as laboratory analysis results and doping control forms etc
are included.
Is the Notifi cation of the Adverse Analytical Finding attached? Yes No
7. Known Sporting Activities
(a) Do you know if the athlete plays or otherwise participates in other sports, apart from the sport to
which the alleged anti-doping violation applies? Yes No
45
Rules of the Sports Tribunal of New Zealand
TITLE FIRST NAME SURNAME
DAY / MONTH / YEAR
Filing and Service Instructions
1. This application should be signed and fi led with the Registrar of the Sports Tribunal at the
address given below.
2. The application should be accompanied by a copy of the applicable constitution, rules or policies
which give the Applicant the basis for applying for provisional suspension.
3. A copy of this application and supporting documents is to be served on the NSO or on Drug Free
Sport New Zealand (If Drug Free Sport New Zealand is not the applicant).
4. The Applicant is to personally serve a copy of this application and attachments on the Athlete
as soon as practical after the original has been fi led with the Tribunal and will forthwith after
service forward to the Tribunal Notice of Service on the form attached.
5. The Tribunal has the right to hear such an application, notwithstanding that service has not been
affected on the athlete.
The Registrar
Sports Tribunal
PO Box 3338
WELLINGTON
Ph: 0800 55 66 80
Fax: 0800 55 66 81
Email: info@sportstribunal.org.nz
Web: www.sportstribunal.org.nz
If so please provide details of those sports below:
(b)
If known, please provide details of the athlete’s sporting commitments over the next 6 months below:
(c)
Please provide any other information you think may be relevant about the athlete’s sporting activities:
Authority
Name
by signing this application certifi es that the signatory is authorised to sign this application on behalf of
the Applicant
Signed
Position Date
Rules of the Sports Tribunal of New Zealand
46
Notice of Service
(to be attached to Form 6)
I,
hereby certify that on the day of 20
I served upon the Athlete, a true copy of the Application for Provisional Suspension and supporting documents.
Attached hereto is a copy of the Application for Provisional Suspension and supporting documents which I
served on the Athlete. I have initialled each page of the Application for Provisional Suspension and supporting
documents as evidence that these are true copies of the documents so served.
A copy of all the aforesaid documents was forwarded to Drug Free Sport New Zealand (if Drug Free Sport
New Zealand is not the Applicant).
Dated the day of 20
Signed
TITLE FIRST NAME SURNAME
DAY MONTH YEAR
DAY MONTH YEAR
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