198  E ORISSA INDUSTRIAL DISPUTES RULES,1959  (F.T_3)

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FORM    T-3

(See Rule   69  (2)

Application under sub section(2) of section 33-C of the Industrial Dispute Act,1947.

                                Before the Labour Court at_____ Between (1) Name of the applicant(s)_______ (2) Name of the employer _________

                                The petitioner ______ a workman of ____ the petitioner's undersigned workmen of Messrs________ of is/are entitled to receive from the said Messrs______ the money/benefits mentioned

In the statement amounts due to the petitioned(s)

                                It is prayed that the Court be pleased to determine the amounts due to the petitioner(s).

                                Station______ Signature or thumb impression(s)  (Address) of the applicant.

                                Date.___________

                                                                                ANNEXTURE

  (Here set out the details of the money due  or the benefits accrues together with the case for their admissibility)

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