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Bare acts > Punjab Maternity Benefit Rules, 1967 > Form G
 
  


 

FORM ‘G’
(See Rule 10)
To
The Competent Authority
Appointed under the Maternity Benefit Act, 1961.
(ADDRESS)
Sir,
I_____________________, the undersigned, woman employee of _______________
(name of the establishment and full address) having been wrongly deprived by the
employer of maternity benefit or medical bonus or both amounting to
Rs._________(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.
Signature or thumb impression
of the woman
Dated______________
Signature of an Attester,
in case the woman is not able to
affix thumb-impression
---------------------

 

 

 

 

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