EARNED LEAVE APPLICATION FORM

Name of the Government Servant Designation Date of Application Name of the present office (in case of deputation) Office to which attached Period of leave at credit Rules by which Government (Leave) Rules, 1972 Nature & period of leave applied for days from 15.07.2013 to and date from which required Ground on which leave applied for Applied with or without Medical Certificate Certificate. Date of return from last leave & the nature Earned Leave. and period of that leave Particulars of salary and allowances drawn Basic + other emoluments. in the present post Address during leave New Model Houses, Govt : : : : : : : : CCS

Earned Leave for 5 19.07.2013 : : : Personal work. Without Medical 15.05.2013

Rs. 25,130/-

: No 40, III Cross,, Woodyard, Near Aranya Bhavan, Mysore-8

Signature of Applicant

Submitted through: recommendation of the Officer.

Signature and Controlling

Date: Designation of Controlling Officer/Sanctioning Authority.

Signature &