Industrial Disputes (Central) Rules, 1957
Application under sub-section (2) of section 33C of the Industrial Disputes Act, 1947
Between______________________ Applicant (s)
And ______________________ Employer
The petitioner , ____________________ a workman of ___________________ M/s , ___________________ of _______________ The petitioners undersigned, workmen 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).
Z Signature or thumb impression (s) of the applicant (s)
(Set out the details of the money due or the benefits accrued together with the case for their admissibility)