CCMA Dispute Referral Intake Form (LRA Form 7.11)

CCMA Dispute Referral Intake Form (LRA Form 7.11)

Provide the details of your dispute and parties so we can complete the CCMA Form 7.11 and flag any missing or time-limit concerns.
Referring Party Details

This is your details
Who is referring the dispute?
First Name
Surname
South African ID Number / Passport Number
Length of Service (months)
Gross Monthly Salary (without deductions)
Net Monthly Salary (with deductions)
Gender
Age
Nationality
Postal Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cellphone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Dispute type

Facts of Dispute

Tell us what happened
Describe your employment history with the employer before the incident/dismissal.
Explain exactly what happened relating to the dispute.
List important dates and events in chronological order.
Describe any meetings, warnings, hearings or consultations.
Explain why you believe the employer acted unfairly.
Identify any witnesses who can support your version.
State what evidence you have (photos, Whatsapps, emails, eye witness)

Mandate
I hereby authorise and mandate Labour Mike and/or any of their representtives to receive, use and store any information provided through this form and hereby instruct them, on their discretion alone, to use the information to complete the necessary forms and/or submit same to the CCMA including submitting the relevant documents to the CCMA for concilliation/arbitration. If Labour Mike chooses to submit said documents or not, I hereby waive any claim against them nor do I hold them responsible for choosing not to submit same for any reason whatsoever. By electing Yes below, I elect, out of my own free will the above.
Signature

Facts of Dispute