Advertisement

Maternity Benefit (Mines and Circus) Rules, 1961

FORM G
[See rule 9]

To

The Competent Authority
(Appointed under the Maternity Benefit Act, 1961).
……(Address)

Sir,

I,…, the undersigned, woman employee of…..(name and full address 1[mine or circus]) have been wrongly deprived by the employer of maternity benefit or medical bonus or both (strike out unnecessary portion} for the reasons attached hereto, prefer this appeal under sub-section (2) of section 12 and request that the said employer be ordered to pay the above mentioned amount to me. A copy of the order of the employer in this behalf is enclosed.

Date…….                                  Signature or 
                                                thumb impression of the woman

Signature of an Attestor in case the woman is
    not able to sign and affixes thumb impression.
         Full address of the nominee/legal representative

1.

Subs. by G.S.R. 59(E), dated 27th February, 1975 (w.e.f. 1-3-1975).

Advertisement

Advertisement
Advertisement
Find a Doctor
Advertisement