Government of India

Department of Space
VIKRAM SARABHAI SPACE CENTRE
Thiruvananthapuram – 695-022

APPLICATION FOR AVAILING LTC

1. Name SC.No. Designation Division/Project

2. Nature of Leave granted No. of Days From To

3. Whether Permanent or Temporary : Permanent/Temporary *

4. Present Basic Pay + SI + NPA :

5. Home Town as declared and recorded

in the Service Book :

6. Place to be visited :

7. Nearest Railway Station :

8. Whether Home Town or Any Place in India :

9. Block Year :

10. Mode of journey & Class of Journey :

11. Train &Train No. :

12. Proposed date of outward journey :

13. Proposed date of return journey :

14. Whether LTC advance is required : Yes/No

15. State whether LTC advance has been

drawn earlier for the same block year : Yes/No

16. Persons in respect of whom LTC is proposed

To be availed including Govt. servant :

Sl.No. Name Relationship Age/Date Employment Monthly

with employee of birth@ Status Income$

@ In case of Children & minor brothers, state date of birth

$ Income includes gross pension and relief thereon
 17. Whether spouse is employed or not : Yes/No

18. If employed, Office/Organisation where

Spouse is employed (give full address) :

19. If employed, state whether spouse is eligible

for LTC from her/his employer (Attach a certificate
to that effect /Joint declaration as the case may be) :

20. State whether any of the family members

for whom the LTC applied now are residing
at a place other than Head Quarters, if Yes
furnish the details :

CERTIFICATE

Certified that my family members (except spouse) for whom LTC advance is applied
for are residing with me at Head quarters/residing at Home Town/studying at other
places and wholly dependent upon me and their individual income is below Rs.1500/-
p.m.

I declare that the particulars furnished above are true and correct to the best of
my knowledge. I undertake to produce the ticket within 10 days of receipt of the
advance.

In the event of cancellation of the journey or if I fail to produce the tickets

within 10 days of receipt of advance I undertake to refund the entire advance in
one lumpsum, with penal interest.

Signature :
Name :
Date : Telephone No :
(Recommendation of the Controlling Officer)

LTC is approved subject to eligibility. Advance applied for by

----------------------------may be granted subject to Rules.
Signature :
Name :
Designation :
Division/Project :
Date: ( Seal to be affixed)
PS: Strike out which ever is not applicable. All columns are to be filled up
properly and completely.
• If LTC advance is required, application should reach Establishment
Section well in advance at least 10 working days for processing the
same.
• In case of temporary Govt. servant a surety bond obtained from a
permanent Govt. servant, in the prescribed format is to be enclosed.