Form XIV

[See rule 40 (5)]

(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 been guilty 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 the management is challenged.) The complainant(s)

accordingly prays/pray that the Conciliation officer/ Arbitrator/ Industrial 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 my knowledge and

that what is stated in paragraphs ........................... above is stated upon information received and

believed by me to be true. This verification is signed by me at on ................................ day of ...........................

20 ...........................

Signature

or Thumb impression of the person verifying.