8/12/2019 Labour Complaint Form

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EMBASSY OF INDIA, RIYADH

[Labour Wing ]

Name of the applicant as per passport

Permanent address in India

Tel No.

Present address in KSA Place/City

PO Box City/Area Code No.

Contact Phone No. Moile No.

Passport No. !ate of Iss"e Place of Iss"e

I#ama No. !ate of Iss"e Place of Iss"e

!ate of arri$al in the Kin%dom

Name of the &mployer/Company

Address of the &mployer/Company Place/City

PO Box City/Area Code No.

Telephone No. 'ax No./&mail I!

Moile No.

Name of the (ecr"itin% A%ent in India

Complete address of the (ecr"itin% a%ent

Telephone No. 'ax No. Moile No.

For official us) *

!o"#lain$ agains$ $% s#onsor &in brif'

i+ Sponsor not fo"nd

ii+ I#ama not prepared / rene,ed

iii+ Salary not paid for ------. months / years

i$+ Ille%al ded"ctions from the salary

$+ Salary and o not %i$en as per contract

$i+ Ill*treatment and harassment

$ii+ (eported y the sponsor as r"na,ay 0"roo+

$iii+ Not sendin% on $acation / emer%ency lea$e &xit*re entry $isa+

ix+ Not pro$idin% medical treatment

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x+ Not sendin% on final exit after settlin% d"es and &SB

xi+ Others ) 11111111111111111111111111111111111111111111111111111111111111

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xii+ (emar2s ) 11111111111111111111111111111111111111111111111111111111111111

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!o"#lain$ agains$ $% rcrui$ing agn$ &if an('

I paid (s. 1111111111 to the (ecr"itin% A%ent thro"%h Mr. 1111111111111111111111

111111111111111111111111111111 Moile No. 11111111111111 Tel No. 111111111111111 + "t I

did not %et o and salary as promised in India.

Promised 3o ) Act"al 3o )

Promised salary ) Act"al Salary )

Note) Please attach photocopy of passport incl"din% $isa endorsement and emi%ration stamped pa%e+I#ama and employment a%reement.

Signa$ur of $% a##lican$

)lac *

Da$ *

Note ) !"ly completed 4ao"r complaint form may please e s"mitted in the 4ao"r 5in% of the&massy et,een 6.77 AM and 89):7 PM on all ,or2in% days for f"rther follo, "p Attach; 4ao"r+ or

TS 4ao"r+ may e contacted.