Form O
[See rules 49 and 50]
Take notice that registration of the agreement to pay compensation said to have been reached between you…………and ………………on the………………20………………has been refused for the following reasons, namely:

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………

Dated………………20…….. Commissioner