Form of application for reference of an industrial dispute to a Board Of

Conciliation
Form A
(See rule 3)

Form of application for the reference of an Industrial Dispute to a Board of Conciliation

……………………………..
Court of Enquiry
……………………………...
Labour Court under section 10(2) of the Industrial
Disputes Act, 1947.
……………………………..
Tribunal
……………………………..
National Tribunal
……………………………..
 
Whereas an industrial dispute ** is apprehended /exists between ………………………...
...........................and it is expedient that **the matters specified in the enclosed statement
which are connected with for dispute, investigation and settlement relevant to the
dispute……………………..should be referred for enquiry by/adjudication

a Board of Conciliation
_________________

a Court of Enquiry
_________________

a Labour Court
_________________ an application is hereby made under sub-section (2)

a Tribunal
_________________

a National Tribunal
 
of section 10 of the Industrial Disputes Act, 1947, that the **said matters /said dispute
 
**a Board of Conciliation.
___________________

a Court of Enquiry.
____________________

should be referred to a Labour Court.

____________________

a Tribunal.
____________________

a National Tribunal.
 
This application is made by the undersigned who have /has been duly authorised to do
has so by virtue of a resolution (copy enclosed) adopted by a majority of the members
present at a meeting of the……………..held on the…………….. 20……………..
 
A statement giving the particulars required under rule 3 of the Industrial Disputes
(Central) Rules, 1957, is attached. Dated the ....................

Signature of employer"..........................
oragent .............................................
or manager.........................................
or principal officer of the Corporation ...............

Signature of the
President of the trade union** .................

Secretary of the trade union ....................

Or
Signature of five representatives duly authorised (vide resolution
enclosed) ...............................................
Or
"Signature of the workman .....................
Or
Signature of the workman in the same establishment duly authorised (vide authorisation
enclosed) ............................
 
To

The Secretary to the Government of India,

Ministry of Labour.
 
Statement required under rule 3 of the Industrial Disputes (Central) Rules, 1957, to
accompany the form of application prescribed under sub-section (2) of section 10 of the
Industrial Disputes Act, 1947:
 
(a) Parties to the dispute including the name and address of the establishment or
undertaking involved;
(b) Specific matters in dispute;
(c) Total number of workmen employed in the undertaking affected;
(d) Estimated number of workmen affected or likely to be affected by the dispute;
(e) Efforts made by the parties themselves to adjust the dispute.
 
Copy to
 
(i) The Assistant Labour Commissioner (Central) ……………..here enter office
address of the Assistant Labour Commissioner (Central) in the local area
concerned;
(ii) The Regional Labour Commissioner (Central);
(iii) The Chief Labour Commissioner (Central), New Delhi.
 
**Delete whichever is not applicable.
Form for agreement between the employer and employees for reference of disputes
to arbitration
Form C
(See rule 1)
Agreement
(Under section 1 OA of the Industrial Disputes Act, 1947)
BETWEEN

Names of the Parties

 
Representing employers:

Representing workmen/workman:

It is hereby agreed between the parties to refer the following dispute to the arbitration
of……………..[here specify the name(s) and address(es) of the arbitrator(s)]:
 
(i) Specific matters in dispute;
(ii) Details of the parties to the dispute including the name and address of the
establishment or undertaking involved;
(iii) Name of the workman in case he himself is involved in the dispute or the name of the
Union. if any, representing the workmen or workman in question;
(iv) Total number of workmen employed in the undertaking affected;
(v) Estimated number of workmen affected or likely to be affected by the dispute.
 
*We further agree that the majority decisions of the arbitrator(s) be binding on us.
 
The arbitrator(s) shall make his (their) award within a period of ............................ (here
specify the period agreed upon by the parties) or within such further time as is extended
by mutual agreement between us in writing. In case the award is not made within the
period aforementioned, the reference to arbitration shall stand automatically cancelled
and we shall be free to negotiate for fresh arbitration.
 
Signature of the parties.

Representing employer.

Workman/Representing workman/workmen.
 
Witnesses
(1)
(2)
 
Copy to:
 
(i) The Assistant Labour Commissioner (Central) ……………….(here enter office
address of the Conciliation Officer in local area concerned).
(ii) The Regional Labour Commissioner (Central) ............................
(iii) The Chief Labour Commissioner (Central), New Delhi.
(iv) The Secretary to the Government of India, Ministry of Labour, Employment and
Rehabilitation (Department of Labour and Employment), New Delhi.
 
*Where applicable.
**Delete whichever is not applicable.
Form for Memorandum of settlement of industrial dispute between employer and
employees
Form H
(See rule 58)
Form for Memorandum of Settlement

Names of Parties
Representing employer(s):
Representing workmen:

Short Recital of the Case

Terms of settlement

Signature of the parties………...........………..

 
Witness:
(1).........................
.............................

(2)……………….
.............................
 
*Signature of Conciliation Officer /Board of Conciliation
 
Copy to:
**(1) Assistant Labour Commissioner (Central) ................................................... [Here
enter the office address of the Assistant Labour Commissioner (Central) in the local area
concerned].
(2) Regional Labour Commissioner (Central) ..........
(3) Chief Labour Commissioner (Central), New Delhi.
(4) The Secretary to the Government of India, Ministry of Labour, New Delhi.
 
*In case of settlements effected by Conciliation Officer/Board of Conciliation
 
**In case where settlements are arrived at between the employer and his workmen
otherwise than in the course of conciliation proceeding.
Application for recovery of money in terms of an award or a settlement
Form K-1
[See rule 6(1)]

Application under sub-section (1) of section 33C of the Industrial Disputes Act,
1947
 
To
 
(1) The Secretary to the Government of India, Ministry of Labour and Employment, New
Delhi.
(2) The Regional Labour Commissioner (Central) ……………. (here insert the name
of the region).
 
Sir,
 
I/We have to state that I am/we are entitled to receive from M/s ……………..a sum of Rs
……………..on account of……………..under the provisions of Chapter V-A/Chapter
V-B of the Industrial Disputes Act, 1947 in terms of the award dated the
........................given by ……………..in terms of the settlement dated the
.................arrived at between the said M/s . ……………..and their workmen
through……………..the duly elected representatives.
 
I/We further state that I/we served the management with a demand notice by registered
post on……………..for the said amount which the management has neither paid nor
offered to pay to me/us even though a fortnight has since elapsed. The details of the
amount have been mentioned in the statement hereto annexed.
 
I/We request that the said sum may kindly be recovered from the management under
sub-section (1) of section 33C of the Industrial Disputes Act, 1947, and paid to me/us as
early as possible.
 
Signature of the applicant(s)

Address(es)
Station…………….. 1.
Date…………….. 2.
3.
4.

ANNEXURE
[Here indicate the details of the amount(s) claimed.]
Application by an authorised representative for recovery of money in terms of an
award or a settlement
Form K-2
[See rule 62(l)]

Application by a person authorised by a workman or by the assignee or heir of a

Deceased Workman under sub-section (1) of section 33C of the Industrial Disputes Act,
1947
 
To
 
(1) The Secretary to the Government of India, Ministry of Labour and Employment,
New Delhi.
(2) The Regional Labour Commissioner (Central) ……………..(here insert the name
of the region).
 
Sir,
 
I *Shri/Shrimati/Kumari……………..have to state that *Shri/ Shrimati /Kumari
……………..is/was entitled to received from M/s . ……………..a sum of Rs.
……………..on account of……………..under the provisions of Chapter V-A/Chapter
V-B of the Industrial Disputes Act, 1947 in terms of the award dated
the ............................ given by ……………../in terms of the settlement dated
the……………..arrived at between the said M/s ……………... and their workmen
through……………..the duly elected representatives.
 
I further state that I served the management with a demand notice by registered post
on……………..for the said amount which the management has neither paid nor offered
to pay to me even though a fortnight has since elapsed. The details of the amount have
been mentioned in the statement hereto annexed.
 
I request that the said sum may kindly be recovered from the management under
sub-section (1) of section 33C of the Industrial Disputes Act, 1947, and paid to me as
early as possible.
 
*I have been duly authorised in writing by…………….. (here insert the name of the
workman) to make this application and to receive the payment of the aforesaid amount
due to him.
 
*I am the assignee/heir of the deceased workman and am entitled to receive the payment
of the aforesaid amount due to him.
 
Station : …………….. Signature of the applicant……………..
Date …………….. Address……………..
Application for determination of the amount from the employer
Form K-3
[See rule 62(2)]
Application under sub-section (2) of section 33C of the Industrial Disputes Act,
1947
Before the Central Government Labour Court at……………..

Between
(1) Name of the applicant(s).
(2) Name of the employer.
 
The petitioner……………..……………..……………..……………..a workman of /The
petitioners undersigned, workmen of M/S ……………..of……………..is/are entitled to
receive from the said M/s. ……………...............the money/benefits mentioned in the
statement hereto annexed.
 
It is prayed that the Court be pleased to determine the amount/amounts due to the
petitioner(s).
 
Address(es)
Station…………….. Signature or thumb-impression(s) of the applicant(s)

Date…………….. 1.
2.
3.
4.
 
ANNEXURE

[Here set out details of the money due or the benefits accrued together with the
case for their admissibility.]
Form of notice of strike to be given by union/workmen in public utility service
Form L
(See rule 71)

Form of Notice of Strike to be given by Union/Workmen in Public Utility Service

Name of Union
[Names of five elected representatives of workmen.]
Dated the……………..day of……………..20……
(The name of the employer)

Address

Dear Sir/Sirs,
 
In accordance with the provisions contained in sub-section (1) of section 22 of the
Industrial Disputes Act, 1947 I/we hereby give you notice that I propose to call a strike /
we we propose to go on strike on……………..20……for the reasons explained in the
annexure.

Yours faithfully,

Secretary of the Union

 
Five representatives of the workmen duly elected at a meeting held on .................. (date),
vide resolution attached.
 
ANNEXURE
Statement of the Case Copy to:

(1)        Assistant Labour Commissioner (Central) . ............................

(Here enter office address of the Assistant Labour Commissioner (Central) in the
local area concerned.)
(2) Regional Labour Commissioner (Central) …………….. Zone.
(3) Chief Labour Commissioner (Central), New Delhi.
Form of notice of lock-out to be given by the employer on a public utility service
Form M
(See rule 72)

Form of notice of lock-out to be given by an employer carrying on a Public

Utility Service

Name of employer ..................................................................................

Address ................................................................................................
Dated the……………..day of……………..20……………..
 
In accordance with the provisions of sub-section (2) of section 22 of the Industrial
Disputes Act, 1947, I/We hereby give notice to all concerned that it is my/our intention to
effect a lock-out, in……………..department(s), section(s), of my/our establishment with
effect from……………..for the reasons explained in the annexure.

Signature……………..
Designation……………..

ANNEXURE
Statement of Reasons.

Copy forwarded to:

(1) The Secretary of the Registered Union, if any.

(2) Assistant Labour Commissioner (Central) ........................
 
[Here enter office address of the Assistant Labour Commissioner (Central) in the local
area concerned.]
 
(3) Regional Labour Commissioner (Central) ……………..Zone.
(4) Chief Labour Commissioner (Central), New Delhi.
Form of report of strike or lock-out in a public utility service
Form N
(See rule 73)
 
Form of report of strike or lock-out in a Public Utility Service Information to be supplied
in this form immediately on the occurrence of a strike or lockout in a public utility
service to the Assistant Labour Commissioner (Central) for the local area concerned.
 
Richa
 
 
Name of Station Normal Number of Strike Date of Cause Was notice of strike
Is there any permanent Any other
under- and working workers or lock- commen- or
lock-out given; if agency or agreement in information
taking district strength involved out cement so on what date and
the undertaking for the
of strike for what period
settlement of disputes
Directly Indi- or lock- between the
employer
rectly out and workmen? If any
exist, particulars thereof
 
1 2 3 4 5 6 7 8 9 10 11
 
richa
 
Notes
 
Column (3) Give the average number of workmen employed during the month
previous to the day on which the strike or lock-out occurred. While reckoning the
average, omit the days on which the attendance was not normal for reasons other than
individual reasons of particular workmen. Thus days on which strike or lock-out occurs
or communal holiday is enjoyed by a large section of workers should be omitted.

Column (4) If say, 200 workers in a factory strike work and in consequence the whole
factory employing 1,000 workers has to be closed then, 200 should be shown under
"directly" and the remaining under "indirectly". If the strike of 200 workers does not
affect the working of the other departments of the factory, the number of workers
involved would only be 200, which figure should appear under "directly" and column
"indirectly" would be blank.

Column (8) Give the main causes of the dispute as well as the immediate cause that led
to the strike or lock-out.
Form of agreement between the employer and workman regarding compensation
for injury caused to workman by accident
Form K
[See rule 48]

Memorandum of Agreement
 
It is hereby submitted that on the……………..day of……………..20……………..,
personal injury was caused to ……………..residing at…………….. by accident arising
out of and in the course of employment in ………......... The said injury has resulted in
temporary disablement to the said workman whereby it is estimated that he will be
prevented from earning more than of his previous /any wage for a
period ............................... . months. The said workman has been in receipt of
half-monthly payments which have continued from the ……………..day of…………
20……………..until the ..........................day of……………..20……………..amounting
to Rs ……………... in all. The said workman's monthly wages are estimated at Rs .
……………..The workman is over the age of 15 years /will reach the age of 15 years on
……………… It is further submitted that………………the employer of the said
workman has agreed to pay, and the said workman has agreed to accept, the sum of Rs
………………in full settlement of all and every claim under the Workmen's
Compensation Act, 1923, in respect of all disablement of a temporary nature arising out
of the said accident, whether now or hereafter to become manifest. It is, therefore,
requested that this memorandum be duly recorded.
 
Dated………………20………………
 
Signature of employer........................................
Witness ............................................................

Signature of workman .......................................

Witness ...........................................................
 
Note.-An application to register an agreement can be presented under the signature of one
party, provided that the other party has agreed to the terms. But both signatures should be
appended, whenever possible.
 
 
Receipt (to be filled in when the money has actually been paid).
 
In accordance with the above agreement, I have this day received the sum of Rs .
………………
Dated………………20……….
..........................Workman
 
The money has been paid and this receipt signed in my presence.
 
......................Witness
 
Note.-This form may be varied to suit special cases, e.g., injury by occupational disease
agreement when workman is under legal disability, etc.
Form of agreement between the employer and workman regarding compensation
for permanent disablement
Form L
[See rule 48]
Memorandum of Agreement
 
It is hereby submitted that on the………………day of………………20…….. personal
injury was caused to………… residing at………………..............by accident arising out
of and in the course of his employment in The said injury has resulted in permanent
disablement to the said workman of the following nature namely:
 
The said workman's monthly wages are estimated at Rs . ........................................ The
workman is over the age of 15 years/ will reach the age of 15 years on . The said
workman has, prior to the date of this agreement, received the following payments,
namely:
 
Rs ………………on………………Rs ………………on………………
Rs ………………on………………Rs ………………on………………
Rs ………………on………………Rs ………………on………………
 
It is further submitted that………………the employer of the said workman has agreed to
pay and, the said workman has agreed to accept the sum of Rs ………………in full
settlement of all and every claim under the Workmen's Compensation Act, 1923, in
respect of the disablement stated above and all disablement now manifest. It is, therefore,
requested that this memorandum be duly recorded.

Dated………………20………………
 
Signature of employer ......................................................................................................
Witness ............................................................................................................................
Signature of workman ......................................................................................................
Witness ............................................................................................................................
 
Note.-An application to register an agreement can be presented under the signature of one
party, provided that the other party has agreed to the terms. But both signatures should be
appended, whenever possible.

 
Receipt (to be filled in when the money has actually been paid).
 
In accordance with the above agreement, I have this day received the sum of
Rs………………
Dated………………20........
………………Workman
 
The money has been paid and this receipt signed in my presence.

.....................Witness

Note.- This form may be varied to suit special cases, e.g., injury by occupational disease,
agreement when workman is under legal disability, etc.
Form of Agreement between the employer and workman regarding compensation
for temporary disablement
Form M
[See rule 48]
Memorandum of Agreement

It is hereby submitted that on the………………day of………………20…….personal

injury was caused to…………… residing at………………by accident arising out of and
in the course of employment in………………The said injury has resulted in temporary
disablement to the said workman, who is at present in receipt of wages amounting to Rs
……..per month / no wages The said workman's monthly wages prior to the accident
are estimated at Rs . .......... The workman is subject to a legal disability by reason
of .................................
 
It is further submitted that………………the employer of the workman has agreed to pay
and………………on behalf of the said workman has agreed to accept half monthly
payments at the rate of Rs . ………………for the period of the said temporary
disablement. This agreement is subject to the condition that the amount of the , half
monthly payments may be varied in accordance with the provisions of the said Act on
account of an alteration in the earnings of the said workman during disablement. It is
further stipulated that all rights of commutation under section 7 of the said Act are
unaffected by this agreement. It is, therefore, requested that this memorandum be duly
recorded.
 
Dated………………20………………
Signature of Employer ................................................................................................
Witness ......................................................................................................................
Signature of workman ................................................................................................
Witness .....................................................................................................................
 
Note.-An application to register an agreement can be presented under the signature of one
party, provided that the other party has agreed to the terms. But both signatures should be
appended, whenever possible.

Receipt (to be filled in when the money has actually been paid).
 
In accordance with the above agreement, I have this day received the sum of
Rs ……………….
Dated …………….....20............ ………………........Workman
 
The money has been paid and this receipt signed in my presence.
................Witness
 
Note.-This form may be varied to suit special cases, e.g., injury by occupational disease,
etc.
Form of notice to the parties for registration of agreement of settlement for
compensation under Workmen's Compensation Act, 1923
Form N
[See rule 49]
 
Whereas an agreement to pay compensation is said to have been reached
between………………and……………… and whereas………………has/have applied
for registration of the agreement under section 28 of the Workmen's Compensation Act,
1923, notice is hereby given that the said agreement will be taken into consideration
on……………… 20………………and that any objections to the registration of the said
agreement should be made on that date. In the absence of valid objections it is my
intention to proceed to the registration of the agreement.
 
......................
Dated………………20…… Commissioner
FORM OF NOTICE BY COMMISSIONER COMMUNICATING REFUSAL FOR
REGISTRATION OF AGREEMENT BETWEEN EMPLOYER AND WORKMAN
REGARDING COMPENSATION

Form O
[See rules 49 and 50]
 
Take notice that registration of the agreement to pay compensation said to have been
reached between you…………and ………………on the………………20………………
has been refused for the following reasons, namely:

………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………
 
Dated………………20……..
Commissioner
Form of notice by Commissioner to the parties to show cause as to why the.
registration of agreement between employer and workman regarding compensation
should not be refused
Form P
[See rule 50]
 
Whereas an agreement to pay compensation is said to have been reached between
………………and .....................and whereas………………has/ have applied for
registration of the agreement under section 28 of the Workmen's Compensation Act,
1923, and whereas it appears to me that the said agreement ought not be registered for the
following reasons, namely:
 
………………........an opportunity will be afforded to you of showing cause
on………………20………………why the said agreement should be registered. If no
adequate cause is shown on that date, registration of the agreement will be refused.

 
..........................

Dated………………20………
Form of notice by Commissioner to a -party to show cause against refusal to register
the agreement between employer and workman regarding compensation
Form Q
[See rule 50]
 
Whereas an agreement to pay compensation is said to have been reached
between ........................and……………… and whereas……………… has/have applied
for registration of the agreement under section 28 of the Workmen's Compensation Act,
1923, and whereas it appears to me that the said agreement ought not be registered for the
following reasons, namely ............................................... …………………......an
opportunity will be afforded to the said of showing cause on……………… 20 why the
said agreement should be registered. Any representation which you have to make with
regard to the said agreement should be made on that date. If adequate cause is then
shown, the agreement may be registered.
 
.........................

Dated………………20…….. Commissioner