Application for Permission under s.

33
of the Industrial Disputes Act (XIV of 1947)
Before (mention here the Conciliation Officer, Board or Tribunal).

In re: …………… Ref. No. ………… of ………… A ………… (Name and address)
Applicant B. …………… (Name and address) Opposite party/ies.

The above-mentioned applicant begs to state as follows:

(Set here all the relevant facts and circumstances of the case and in particular the
grounds on which the permission is sought for).

The applicant, therefore, prays that the express permission may be granted to him to take
inter alia the following action/s, namely:

[Mention here the action/s specified in cl. (a) or (b) of s. 33 of the Act.]

Dated this ……… day of ………

Signature of the applicant

Date of verification ………….... Signature of the person verifying

Place of verification ……………

* * * * *

Complaint under s. 33A of the Industrial Disputes Act 1947

A ……………………............................. (full name, description and

address) Complaint/s; and

B ………………..................................... (full name, description and

address) Opposite party/ies

The petitioner/s begs/beg to complain that the opposite party/ies has/have been guilty of
wilful contravention of the provisions of s. 33 of the Industrial Disputes Act (XIV of 1947) as will
appear from the particulars set out below:

(Here set out briefly the particulars showing the manner in which the alleged
contravention has taken place and also the grounds on which the order or act of the management
is challenged.)

(The complaint/s accordingly pray/s that the tribunal may be pleased to decide the
complaint set out above and pass such orders thereon as it may deem fit and proper.)
The number of copies of the complaint and its annexures required by r. 59 of the Industrial
Disputes (Central) Rules 1957, are submitted herewith.

Dated this ………… day of …………

 Signature or thumb impression
of complaint/s

Verification

I do solemnly declare that what is stated in paragraphs ……… above is true to my

knowledge and that what is stated in paragraphs ……… above is stated upon information
received and/believed by me to be true. Verification is signed by me at …………… on …………
day of ………….

Signature or thumb impression

of the person verifying

* * * * *
Form of Application by an Employee
under section 20(2) of the Minimum Wages Act 1948

In the Court of the Authority appointed under the Minimum Wages Act 1948 for ………… Area.

Application No. ………… of 19………

(1) ....................................................

(2) .................................................... Applicant/s

(3) ....................................................

through ………… a legal practitioner …………… Official of ……… Union which is a

registered Trade Union.

Address ...............................................

versus

(1) ....................................................

(2) .................................................... Opponents

(3) ....................................................

The applicant/s above-named beg/s respectfully to submit as follows:

1. That …………………………

2. That …………………………

The applicant/s has/have been paid wages at less than the minimum rate of wages.

The applicant/s estimate/s the value of the relief sought by him/them at the sum of Rs.
………….

The applicant/s pray/s that a direction may be issued under sub-sec. (3) of s. 28 for—
 (a) payment of the difference between the wages due according to the
minimum rate of wages fixed by the Government and wages actually paid, and

(b) compensation amounting to Rs. ……………

The applicant/s beg/s leave to amend or add to or make alterations in the
application, if any, and when necessary.

Date ………………

Signature or thumb impression of the

employee/s or legal practitioner or
official of a registered trade union duly
authorised.

* * * * *

Application by an Inspector or Person

Acting with the Permission of the Authority
under section 20(2) of the Minimum Wages Act 1948

In the Court of the Authority appointed under the

Minimum Wages Act 1948, for ………… area

Application No. …………… of 19……

(1) ……………………………………

Address ……………………… Applicant

Versus

(2) ………………………………………

Address …………………… Opponent

The applicant above-named begs respectfully to submit as follows:

1. That ……………………

2. That ……………………

The opponent is bound to pay wages at the minimum rate of wages fixed by the
Government, but he has paid less wages to the following employees:

(1) ………………………

(2) ………………………

(3) ………………………

The applicant estimates the value of the relief sought for the employees at the sum of Rs.
……………
The applicant prays that a direction may be issued under sub-sec. (3) of s. 20 for—

a) payment of the difference between the wages due according to the minimum rate
of wages fixed by the Government and wages actually paid and

(b) compensation amounting to Rs. ……………

The applicant begs leave to amend or add to or make alterations in the application if and when
necessary.

Date …………… Signature ………………

The applicant does solemnly declare that what is stated above is true to the best of his
knowledge, belief and information. The verification is signed at ………… on
……… day of ………… 19….

* * * * *
Individual Application

[See sub-sec. (2) of s. 15 of the Payment of Wages Act]

In the Court of the Authority appointed under the Payment of Wages Act (IV of 1936) for
………… area.

Application No. ………… of ………… 19………

Between ABC …………

(through a legal practitioner) Applicant

an official of ………… which is a

registered trade union And XYZ ……… Opposite Party

1. ABC is a person employed in/or the …………………………

Factory
……………………………………
Railway entitled ………… and
……………………………………
industrial establishment
resides at …………….

The address of the applicant for the service of all notices and processes is:

2. XYZ, the opposite party, is the person responsible for the payment of his wages under
s. 3 of the Act and his address for the service of all notices and processes is:

3. (1) The applicant’s wages have not been paid for the following wage period(s) (give
date). Or

A sum of Rs. ……………… has been unlawfully deducted from his wages of (amount) for
the wage period(s) which ended on [give date(s)].
 (2) Here give any further claim or explanation.

4. The applicant estimates the value of the relief sought by him at the sum of Rupees
………….

5. The applicant prays that a direction may be issued under sub-sec. (3) of s. 15 for—

(a) Payment of his delayed wages as estimated or such greater or lesser

amount as the authority may find to be due. Or
Refund of the amount illegally deducted.

(b) Compensation amounting to …………

The applicant certifies that the statement of facts contained in this application is to the
best of his knowledge and belief accurate.

Signature or thumb impression of the

employed person, or legal practitioner or
official of a registered trade union duly
authorized.

* * * * *

Group Application

[See sub-sec. (2) of ss. 15 and 16 of the Payment of Wages Act 1936]

In the Court of the Authority appointed under the Payment of Wages Act (IV of 1936) for
……… area.

Application No. ………… of 19…………

Between ABC and state the number ………… others …………

Applicants
(Through a Legal Practitioner)
an official of …………..……… which is a
registered trade union And XYZ ………. Opposite party

The applicants state as follows:

1. The applicants whose names appear in the attached schedule are persons employed
in the factory.

on Railway entitled ……………

Industrial establishment

The addresses of the applicants for service of all notices and processes are:

2. XYZ, the opposite party, is the person responsible for the payment of wages under s. 3
of the Act, and his address for the service of all notices and processes is:
 3. The applicants’ wages have not been paid for the following wage period(s).

4. The applicants estimate the value of the relief sought by them at the sum of Rupees
……… .

5. The applicants pray that a direction may be issued under sub-sec. (3) of s. 15 for—

(a) Payment of the applicants’ delayed wages as estimated ………… or

such greater or lesser amount as the authority may find to
be due.

(b) Compensation amounting to …………

The applicants certify that the statement of facts contained in this application is to the
best of their knowledge and belief accurate.

Signature or thumb impression of two of

the applicants or legal practitioner/an
official of a registered trade union duly
authorised

Schedule

Name of applicants

(1) ……………………

(2) ……………………

(3) ……………………

(4) ……………………

* * * * *

Application by an Inspector or Person

Permitted by the Authority or Authorised to Act
[See sub-sec. (2) of ss. 15 and 16 of the Payment of Wages Act]

In the Court of the Authority appointed under the Payment of Wages Act, for ……… area.

Application No. ………… of 19…………

Between ABC (designation ………… an Inspector under the Payment of Wages Act).

permitted by the authority

(or a person
–––––––––––––––––––––– to act under sub-sec. (2) of
authorized.
s. 15) ……………………………
 Applicant

And XYZ, the opposite party, is the person responsible under the Act for payment of
wages to the following person(s):

(1) ……………………

(2) ……………………

(3) ……………………

*
*
*

2. His address for the service of all notice and processes is:

3. The wage of the said person(s) due in respect of the following wage
have not been paid
period(s) –––––––––––––––––––––––––––––––––––––––––––––––––––––
have been subjected to the following illegal deductions

4. The applicant estimates the value of the relief sought for the person(s) employed at the
sum of Rs. ………….

5. The applicant prays that a direction may be issued under sub-sec. (3) of s. 15 for—

(a) Payment of the delayed wages as estimated or such greater or lesser

amount as the Authority may find to be due:
Or
Refund of the amount illegally deducted.

(b) Compensation amounting to …………… .

The applicant certifies that the statement of facts contained in this application is to the
best of his knowledge and belief accurate.

Signature

* * * * *
Application under Workmen’s
Compensation Act for Compensation by Workmen
To the Commissioner for Workmen’s Compensation …………
residing at ………………………… Applicant

versus

residing at ………… Opposite party

It is hereby submitted that—

 1. The applicant, a workman employed by (a contractor with) the opposite party on the
………… day of ………… 19………, received personal injury by accident arising out of and in the
course of his employment.

The cause of the injury was (here insert briefly in ordinary language the cause of injury)
……………
………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

2. The applicant sustained the following injuries, namely:

………………………………………………………………………………………………………..

3. The monthly wages of the applicant amount to Rs. …………

is over
The applicant –––––– the age of 15 years.
under

4. (a) Notice of the accident was not served on the …………......... day
of …………….

(b) Notice was served as soon as practicable.

(c) Notice of the accident was not served (in due time) by reason
of ………….…

The applicant is accordingly entitled to receive—

(a) half-monthly payment of Rs. ………… from the ……………… day of ………
1999 to ……………

(b) a lump sum payment of Rs. ………………

5. The applicant has taken the following steps to secure a settlement by agreement,
namely—

but it has proved impossible to settle the questions in dispute because …………

You are, therefore, requested to determine the following questions in dispute, namely—

(a) whether the applicant is a workman within the meaning of the Act;

(b) whether the accident arose out of or in the course of the applicant’s
employment;

(c) whether the amount of compensation claimed is due, or any part of that
amount;

(d) whether the opposite party is liable to pay such compensation as is due;

(e) etc. (as required).

Dated ………… 19 …… Applicant

 * * * * *
Application under Workmen’s
Compensation Act for Order to Deposit Compensation
It is hereby submitted that—

1. ………………a workman employed by (a contractor with) the opposite party on the

…………… day of ………… 19……… received personal injury by accident arising out of and in
the course of his employment resulting in his death on the ……… day of ………… 19………. The
cause of the injury was (here insert briefly in ordinary language the cause of the injury) …………

is a
2. The applicant(s) ––––––– dependant(s) of the deceased workman
are
being his ……………............

3. The monthly wages of the deceased amount to Rs. ………….

over
4. The deceased was –––––– the age of 15 years at the time of his death.
under

5. (a) Notice of the accident was served on the …………… day of …………

(b) Notice was served as soon as practicable.

(c) Notice of the accident was not served (in due time) by reason
…………… of ………….

6. The deceased before his death received as compensation the total sum of Rs. .
……………….
is
The applicant(s) –––––– accordingly entitled to receive a lump sum payment
are
of Rs. ………….

You are, therefore, requested to award to the applicant(s) the said compensation or any
other compensation to which he may be entitled.

Dated ………… Applicant(s)

Dated the ………… day of ……… 19
……

* * * * *
Application for Registration of a Trade Union
1. We hereby apply for the registration of a trade union under the name
of ………….

2. The address of the head office of the union is …………….

 3. The union came into existence on the ………… day of ………… 19…… and has on its
roll on the date of this application ……… members.

4. The union is a union of employees/workers engaged in the ……… industry (or

profession).

5. The particulars required by s. 5(1)(c) of the Indian Trade Unions Act 1926, are given in
Schedule I.

6. The particulars given in Schedule II show the provisions made in the rules for the
matters detailed in s. 6 of the Indian Trade Unions Act 1926.

7. (To be struck out in the case of unions which have not been in existence for one year
before the date of application). The particulars required by s. 5(2) of the Indian Trade Unions Act
1926, are given in Schedule III.

8. We have been duly authorised to make this application by ……….

9. Written declaration from the officers of the trade union that they had given their
consent to their being elected as such officers is given in Schedule IV.

Signature Occupation Address

Signed 1.

2.

3.

4.

6.

To
The Registrar of Trade Unions, West Bengal

Schedule I

List of Officers

Title Name Age Address Occupation

 Schedule II

Reference to Rules

The number of the rules making provision for the several matters detailed in column are
given in column 2 below:

1 2
Matter Number of rules

Name of Union …………… The whole of the

objects for which the union has been
established ………… The whole of the
purposes for which the general funds of the
union shall be applicable. The maintenance
of a list of members ………… The facilities
provided for the inspection of the list of
members by officers and members ………
The admission of ordinary members
………………… The admission of honorary
or temporary members ………

The conditions under which members are

entitled to benefits assured by the rules
……… The conditions under which fines or
forfeitures can be imposed or varied ………
The manner in which the rules shall be
amended, varied or rescinded ………… The
manner in which the members of the
executive and the other officers of the union
shall be appointed and removed ……… The
safe custody of the fund ……… The annual
audit of the accounts …………The facilities
for the inspection of account books by
officers and members ………… The manner
in which the union may be dissolved
………….................

Schedule III

(This need not be filled in if the union came into existence less than one year before the
date of application for registration). Statement of Liabilities and Assets on the ……… day of
……… 19……….
Liabilities Rs. p Assets Rs. p.

Amount of general fund Cash—

Amount of political fund In hands of Treasurer ………

Loans from: In hands of Secretary ………
………….. In hands of …………………. ……………
…………… In the ……….... Bank ..........
…………… Securities as per list below,
unpaid subscriptions due

Loans to—
…………..
……………
Debts due to— ……………

…………..
……………

Other liabilities Immovable property

(to be specified)— Goods and furniture
………….. Other assets (to be
…………… specified)
…………… …………..
……………

Loans from:

Total Liabilities

Total Assets

List of Securities

Particulars Nominal value Market value In hands of

Signed 1.

2.

3.

4.

5.
 Schedule IV

We hereby declare having consent to our being elected as officers of the ………… (name
of the trade union):

Signature Designation

Signed:

1 … …

2 … …

3 … …

4 … …

5 … …

6 … …

7 … …

8 … …

9 … …

10 … …

11 … …

12 … …

13 … …

14 … …

15 … …

* * * * *
Sickness or Temporary Disablement Benefit Claim for Benefit
I …………..........……................ s/w/d of …………….....…..........…................
Insurance No. ……………………… hereby state that I was certified sick/
temporarily disabled from ………… a.m./p.m. on the ………… day of ……… 19………
and I have not been at work since ………… a.m./p.m. on the day of ………… 19………

I no longer claim to be sick/temporarily disabled from ………… day of ………… 19………

and I shall/did not take up any work for remuneration before that day.*

I claim benefit accordingly. I desire payment in cash at local office/by money order
present/last employer ……………… Department ………… Occupation ………… shift (if any)
………… present address ………

Signature or thumb impression

Local Office ……………

* Strike out if not applicable, and then, before resuming work, a final certificate must be obtained.

* * * * *

Accident Case Only

Date, time and place of accident …………. If a notice of the accident had not been given to the
employer, state briefly on a separate paper how the accident happened.
Signature or thumb impression

* * * * *

Sickness or Temporary Disablement Benefit Claim for Benefit

I, ……………....................., s/w/d of ………………………… Insurance
No. …………………………… declare that because of sickness/temporary disablement, I have
not been at work since the date of last/first certificate sent to you.
I claim benefit accordingly. I desire payment in cash at local office/by money order.

Signature or thumb impression

Date ………… Local office ………………
Present Address …………………

* * * * *

Claim for Permanent Disablement Benefit

I, ……………...................................., s/w/d of ……………………… Insurance No.

……………………having been declared as permanently disabled by
the Medical Board/Appeal Tribunal claim permanent disablement benefit accordingly for the
period from ………… to ……………
The amount due may be paid to me by money order/in cash at local office.

Date ………… Signature or thumb impression

Present Address ………………

ANOTHER FORM

I, ………………………………… s/w/d of …………………………...............

Insurance No. ……………… declare that, because of sickness/temporary disablement, I have
not been at work since the date of last/first certificate sent to you.

I no longer claim to be sick/temporarily disabled ………… from ……… day of ……… 19…………
and I shall/did not take up any work for remuneration before that day, I claim benefit accordingly. I
desire payment in cash at local office/by money order.

Signature or thumb impression

Date ………… Local office ……………
Present Address …………………

* * * * *
Dependants’ Benefit
CLAIM FORM

Claim arising from the death on ………… of (insured person) …………….. s/w/d of …………
having Insurance No. …………………… and that employed as ………… by …………….

I/We, the following, being dependants of the deceased insured person, whose particulars
are given above, apply for dependants’ benefit in respect of his/her death.

Nature of the Date of birth Relationship sex Marital Name of the

dependants or age With the status guardian in
deceased case of a
minor
1 2 3 4 5 6

So far as I/we know, the following are the only other dependants who may be entitled to
dependants’ benefit in respect of the death of the above-named insured person.

Names and Date of birth Relationship sex Marital Name of the

address of or age With the status guardian in
the deceased case of a
dependants minor
1 2 3 4 5 6

I/We declare that the particulars given above are true to the best of
my/our knowledge and belief.
 Signatures Present Addresses

1. ………………………

2. ………………………

3. ………………………

4. ………………………
†
Certified that the declarations made above are true to the best of my knowledge and
belief.

Rubber stamp or seal of

the attesting authority
Signature ………..……
Designation .............…

Important: Any person who makes a false statement or representation for the
purpose of obtaining benefit, whether for himself or for some other
persons, renders himself liable to prosecution.
† This certificate is to be given by (i) an officer of the Revenue, Judicial or
Magisterial Departments of Government; or (ii) a Municipal
Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv)
the Head of the Gram Panchayat under the official seal of the Panchayat;
or (v) any other authority approved by the appropriate Regional Office.

* * * * *

Maternity Benefit

CLAIM FORM

I ………… Insurance No. …………………………wife of/daughter of ………… here claim

maternity benefit with effect from the ………… day of ………… 19……… I hereby declare that I
have ceased/shall cease to work for remuneration with effect from that date.

Present/last employer …………………........................................

Department, shift and occupation …………...............................

Present address …………….........................................................

Date ……………

Signature or thumb impression

* * * * *