Form XIV

(See rule 40)

(Application to be submitted before the Tribunal in the matter not settled

by the conciliation officer )

Before………….........… (here mention the name of the Tribunal having jurisdiction over the area)

In the matter of:

............................................ Applicant

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

Versus

.............................................................. Opposite party (ies)

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

The above mentioned applicant begs to state as follows:-

(Here set out the relevant facts and other details of the case).

The applicant prays that the instant dispute may please be admitted for adjudication and request to

pass appropriate Award.

Signature of the applicant(s)

Address(es)

Station:

Date:.