SOUTHERN RAILWAY

CHENNAI DIVISION

APPLICATION FOR GRANT OF LEAVE TO BE AVAILED OUTSIDE INDIA

( TO BE SUBMITTED IN DUPLICATE )
1.

NAME OF THE EMPLOYEE

2. DESIGNATION & OFFICE AT WHICH WORKING

3. PAY & SCALE OF PAY

4. DATE OF BIRTH
5. DATE OF APPOINTMENT
6. DATE OF CONFIRMATION
7. DATE FROM WHICH LEAVE IS REQUIRED
TO BE AVAILED OUT OF INDIA.
8. NATURE OF LEAVE APPLIED FOR
9. REASON FOR APPLYING FOR LEAVE OUT OF INDIA
10. PASSPORT NO:
11. DETAILS OF PRIVATE FOREIGN TRAVEL
TO BE UNDERTAKEN
Period of
Abroad
From - To

Name of
Foreign
Countries
to be
visited

Purpose

Estimated
expenditure
(Travel
Boarding
Lodging Visa
/Misc

Source of Funds

Remarks

12. DETAILS OF PROVIOUS PRIVATE FOREIGN

TRAVEL, IF ANY, UNDERTAKEN DURING THE
LAST FOUR YEARS (AS UNDER IMTEM NO.11 )
Period of Abroad
From - to

Name of
Foreign
Countries
to be
visited

Purpose

:
Estimated
expenditure
(Travel
Boarding
Visa /Misc

Source of Funds

SIGNATURE:
DESIGNATION:

SIGNATURE & DESIGNATION OF THE

IMMEDIATE SUPERIOR.

FOR OFFICE USE ONLY

FORWARDED TO Sr.DPO/MAS

SIGNATURE

DESIGNATION

STATION

Remarks

APPLYING FOR AVAILING LEAVE OUTSIDE INDIA

Designation

and Station
In Scale of Rs:

on Pay Rs:
with date of confirmation

request the

administration to sanction out of India from

to

The reason for leave applied :

DECLARATION
I hereby declare that while out of India on Leave, I will not take any service, or
accept any employment with out obtaining prior sanction of the President as laid down in
Rule 509 IR nor I will engage in any business, profession or vocation without prior sanction
and that I will not extend EX India Leave for abroad.
I am fully aware of consequence arising out of this action and or absence after the
expiry of the sanctioned leave.

Signature

Name

Designation :
Station

Date