Form XVII

(See Rule 58)

(Complaint under Section 91 of the Industrial Relation Code, 2020)

Before the Conciliation officer/ Arbitrator/ Tribunal or, National Tribunal……………….

In the matter of :................................... Reference No…………………………………….

A...................... Complainant(s);

Versus

B...................... Opposite Party(ies).

Address:

The petitioner(s) begs/beg to complain that the Opposite Party(ies) has/have

beenguilty of a contravention of the provisions of section 90 of the Industrial Relation code,

as shown below:

(Here set out briefly the particulars showing the manner in which the alleged contravention

has taken place and the grounds on which the order or act of themanagement is challenged.)

The complainant(s) accordingly prays/pray that the Conciliation officer/ Arbitrator/

Industrial Tribunal or National Tribunal may be pleased to decide the complaint set out above

and pass such order or orders thereon as it may deem fit and proper.

The number of copies of. the complaint and its annexure required under rule 91 of the

Industrial Relation Code are submitted herewith.

Dated this............day of............20. Signature of the Complainant(s)

Verification

I do solemnly declare that what is stated in paragraph above is true to

myknowledge and that what is stated in paragraphsabove is stated upon information received

andbelieved by me to be true. This verification is signed by me at......................... on the

……………dayof....................20.....................

Signature

or Thumb impression of the person verifying.