FORM G
[Rule 9]
APPEAL

To
The Competent Authority
(Appointed under the Maternity Benefit Act, 1961)
________ (Address)
Sir,
            I, ______, the undersigned, woman employee of ______ (name and full address 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
Date _______ Signature of an Attestor in case the woman is not able to sign and affixes thumb impression. Full address of the nominee/ legal representative