APPLICATION FOR DETERMINATION OF THE AMOUNT FROM THE EMPLOYER

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[See rule 62(2)]

Application under sub‐section (2) of section 33C of the Industrial Disputes Act, 1947

Before the Central Government Labour Court at……………..

Between

(1) Name of the applicant(s).

(2) Name of the employer.

The petitioner…………………………………………………………..a workman of /The

petitioners undersigned, workmen of M/S ……………..of……………..is/are entitled to receive

from the said M/s. …………………………the money/benefits mentioned in the statement hereto

annexed.

It is prayed that the Court be pleased to determine the amount/amounts due to the petitioner(s).

Address(es)

Station…………….. Signature or thumb‐impression(s) of

the applicant(s)

Date…………….. 1.

2.

3.

4.

ANNEXURE

[Here set out details of the money due or the benefits accrued together with the case for their

admissibility.]