Joint Committee on Public Petitions Houses of the Oireachtas Leinster House

Dublin 2

Tel: 01 618 4215 Email: submitapetition@oireachtas.ie

Petition to the Joint Committee on Public Petitions

SECTION 1 - ABOUT YOU (This information will not be made public):

Information provided in this section is required to allow the secretariat to contact the Petitioner about their petition.

Give details of the person who is lodging the Petition (whether on their own behalf or on behalf of another).

Title: (e.g. Mr. Mrs. etc): |__|__|__|__|__|__|__|__|__|

First Name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Surname: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

County: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Post Code: |__|__|__|__|__|__|__|__|__|__|

Address (Line 1): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Address (Line 2): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Address (Line 3): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Home Telephone: |__|__|__|__|__|__|__|__|__|__|__|__|__|

Mobile Telephone: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|@

|__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|

Confirm E-mail |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|@

Address: |__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|

How would you prefer us to contact you?

Post Home Telephone

Mobile Telephone E-mail

Have you (or the petitioner, if you are not the petitioner) raised this issue with any of the following:

1. An Ombudsman

Yes No

2. A regulatory public body

Yes No

3. A body established for purposes of redress

Yes No

Have you had a response in relation to the issue?

Yes No

Date of Response: __ __/__ __/__ __

Reference Number (if any) of Response: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Have you had a response in relation to the issue?

Yes No

Date of Response: __ __/__ __/__ __

Reference Number (if any) of Response: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Have you had a response in relation to the issue?

Yes No

Date of Response: __ __/__ __/__ __

Reference Number (if any) of Response: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Other action taken to resolve issues of concern before submitting the Petition:

Should the Joint Committee on Public Petitions consider it necessary to invite you to appear before it to speak on your petition, would you wish to appear?

Yes No

Section 2 - About your Petition (This information will be made public):

* If the name entered below is different from the person lodging the petition, full agreement from the petitioner should already have been obtained.

Title: (e.g. Mr. Mrs. etc): |__|__|__|__|__|__|__|__|__|

First Name of Petitioner: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Surname of Petitioner: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Petition Title:

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|_

_|__|__|

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|_

_|__|__|

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|_

_|__|__|

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_|__|__|

Submitted From:

Individual Corporate Body Unincorporated association of persons

If petition is submitted from a Corporate Body:

Corporate Name:

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

__|

|__|__|__|__|__|__|__|__|__|

If petition is submitted from an unincorporated association of persons

Unincorporated Association Name:

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

__|

|__|__|__|__|__|__|__|__|__|__|__|__|

Section 3 – Details of the Petition (This information may be made public at the discretion of the Committee):

Text of Petition (limit 250 words):

Other background information to Petition (may include information already provided in section 1):

What action are you suggesting in response to your petition?:

Individual Action as the Committee considers appropriate

Refer the Petition to any other Committee with a request for further consideration and report back to the Committee

Report to the Dáil/Seanad with recommendations and include a request that the report bne debated by the Dáil/ Seanad

Refer the petition to the Ombudsman with a request for further consideration and report back to the Committee

Other

If other, please give details below:

Please tick this box giving us permission to make section 2 of your petition public and to make section 3 public at the discretion of the Committee:

Yes

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Please tick this box confirming you have full agreement from all parties listed above to the publication of their names and other details provided [_]

Joint Committee

on Public Petitions

Joint Committee on Public Petitions

Houses of the Oireachtas

Leinster House, Dublin 2

Teil: (01) 618 4215

Email: submitapetition@oireachtas.ie

Please be advised you must have full agreement of all parties listed below to the publication of their names and other details

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