ABV – INDIAN INSTITUTE OF INFORMATION TECHNOLOGY & MANAGEMENT

GWALIOR

Leave Application Form - Nilgiri Boys Hostel (BH-2)
Date:..../...../............
1. Name of student:--------------------------------------------------------------------------------------------------------2. Roll No:

-----------------------------------------------------------------------------------------------------------

3. Hostel Room No:-------------------------------------------------------------------------------------------------------4. Program/Discipline (IPG/MBA/M.Tech/Ph.D):-------------------------------------------------------------------5. Period of Leave: From ------------------------------ To -------------------------------------------------------------6. Reason for leave:-------------------------------------------------------------------------------------------------------7. Address during leave with contact no

(Mandatory) :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------8. Parent’s address with phone no and E-mail
id:---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------9. Local Guardian’s address with phone no and E-mail id:

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------10. Undertaking: - I will be solely responsible for any incident during the period of leave.

(Signature of the Student)
11. He may/may not be granted leave for the purpose stated.

(Course Co-ordinator)

Leave for the above mentioned period is Granted/ Not Granted.ABV – INDIAN INSTITUTE OF INFORMATION TECHNOLOGY & MANAGEMENT GWALIOR 12. Medical certificate to be attached (issued by the Institute Doctor) in case of leave on medical ground. Leave Application should be granted by the warden at least one day prior to the date of leave. Nilgiri Boys Hostel. (Warden. 2. BH-2) Note:1. .