SAMPLE PETITION

This form is designed to help you prepare the front page of a petition. Subsequent pages
need to include only the ‘request’ of the petition, with names and signatures below it.
For more information contact the Petitions Committee
petitions.committee.reps@aph.gov.au or by phone (02) 6277 2152

ADDRESS
TO THE HONOURABLE THE SPEAKER AND MEMBERS OF Petitions must be
addressed to the
THE HOUSE OF REPRESENTATIVES House of Representatives

Here insert words

This petition of … describing who the
petition is from, e.g.
‘Certain citizens of
draws to the attention of the House: Australia’

REASON
This must be a matter
on which the House
has power to act - a
We therefore ask the House to: Commonwealth legislative
or administrative matter

REQUEST
Note: the address,
reason and the request
PRINCIPAL PETITIONER together comprise the
‘terms’ of the petition and
Name: ____________________________________________ Signature: ___________________________________________ together must not exceed
250 words
Address:_______________________________________________________________________________________________________
CONTACT DETAILS for
__________________________________________________________________________________ Postcode: __________________ PRINCIPAL PETITIONER
This information is only
Email (if available): ________________________________________ Telephone:_______________________________ for the use of the Petitions
Committee. It will not be
published, however once
the petition is presented it
NAME AND SIGNATURE will be available for public
perusal

1. SIGNATURES OF
OTHER PETITIONERS
2.
• If required, attach
additional pages for
3. signatures
• The request must
4.
appear at the top of
each additional page
5.
• Other information such
as postal addresses
6.
may also be provided
but they are not
7. required. As such,
petitions seeking this
8. information should note
a ‘voluntary’ field
9. • Signatures on the
reverse of a petition,
10. or on a blank page,
will not be counted