Form III

(See rule 41)

Appeal under Section 49(1) of the Code on Wages, 2019

Before The Appellate Authority under the Code on Wages, 2019

A.B.C

Address………………………………………………………………………………………

………..APPELLANT

Vs.

C.D.E.

Address………………………………………………………………………………………

…… RESPONDENT

DETAILS OF APPEAL:

1. Particulars of the order against which the appeal is made :

Number and date :

The authority who has passed the impugned order:

Amount awarded:

Compensation awarded , if any :

2. Facts of the case :

(Give here a concise statement of facts in a chronological order, each paragraph containing

as nearly as possible a

separate issue or fact).

3. Grounds for appeal :

4. Matters not previously filed or pending with any other Court or any Appellate Authority:

The appellant further declares that he had not previously filed any appeal, writ petition or

suit regarding the matter

in respect of which this appeal has been made, before any Court or any other Authority or

Appellate Authority nor

any such appeal, writ petition or suit is pending before any of them.

5. Reliefs sought :

In view of the facts mentioned above the appellant prays for the following relief(s) :—

[Specify below the relief(s) sought]

6. List of enclosures:

1.

2.

3.

4.

………..

Date :

Place :

Signature of the appellant.

For office use

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Date of filing

or

Date of receipt by post

Registration No.

Authorized Signatory