um ....

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S.R. - 1
FORM OF APPLICATION FOR LEAVE
(~ f.rqq 216 ~fuPt) I (See supplementruy Rule 216)
R-cqufl :- ~ B'. I ~ I' ~ mm <it 'f{;fi ~.
I.
~ ~ \lJrQm it '.ij ::~HI'~p~r~(\
I
Note ;- lIems 1 10 11 must be filled i:'I by all applicants whether gazelled or non-gazelled.
I. >n~l C{1I"ff11/Name of applicant
2. Bfi1~ mcnB1~ r1~LMctl
Leaverulesapplicable
J. 1:pJPost held
4. AWT. <w~ict~ 31t\ 31:!'I{\ll
Department. vf/ice and Section
5. cm:=!/Pay
(1. cuitTR ~ ~ ~ Cffi11%A ~ \\rt1 tnrf1
\fill 1.1T~T?! ~ \fit I
, Houserentallowance,conveY3nceallowanq{or other
compensatory
allowances
drawnin thepresentpost. ~
7.
~ rrm ~ Cfi1~ ~~ ~ ~ IfF m.<t>i
~/Nature and period01leaveappliedlor Ind date
fromwhichrequired. .
~. . rf;:rcm ~ ~ cf;ftI. m~ ii. ~ i~ TI
<mB/~~iT ~ qm1 tl
. I
Sundaysandholidays.il any.prolX'sedto beprefixed!
sulfixedtoleave.
Y. ~Cfil<iiT\U11
Groundonwhichleaveis appliedlor,
10. fuFil <Pfr
'{';-' iT 00
<ti1?rim 3fn ~ v~~1
-> ' ~ ~
i1~ 3V-ff~ I
Date 01return from lastleal/e, and the nature iJnd period
of that leave,
II. iro f.:r;:m~r ~"',~. it [; uvs qql .;, fut1. ~~~;I~1
->" q;1 ~ m<fiT%Rit'
t II propose/do not propose 10 ava:! myself o( leave Iravel concession in the block
years , during Ihe e }' uing leave,
12. (Cf;) i'j r.rr:r1tn if f-:n~fllli! i,r(R ~a-'/IM1!~Jtl Til <i>l>~[I~ -q'f<3T'.71l{\~~[1 -.tR ~m ,31P~:jt'r.m
iRR/:}TI ~~~{l-J<I1Ti~T U f11ffi ircP i;: ~ ( -;:it11:1TW1 q;i cncr1 tf)l ~TTJit ~~;,~')Cfi1WT1~
TTI 31~R1 ~ ~'m1 irt ire« ~ ~ q;1 ~~-fu # 1@ f:rI4 1\1 ,( ~ ) (ii) tmTIft-m~~~I
f.rrqrcm1. 1933 ~ f.rrq II (71) (iii) ~ BJ1l ~ ~ '1 imtl m '

(lI) I undertake10refundIhe differencebetweenthe leavesalarydrawnduringleaveon averagepayl

commutedleaveand Ihal admissibleduringleaveon hall averagepay/hallpayleave,whichwould
not havebeenadmissibfeh~d Ihe prO'/i~o10fA. 81 (b) (ii) I rule 11 (c) (iii) ollhe RevisedLeave
Rules,1933,not beenapplied-inthe ~~nt 01my retirementIrom serviceallhe end of during the
currencyof Ihe leave .I
 12. «(9) it ~ ~ ( f<o irl ~~l{f~. Wo f.v.p.t m ~ irco ~ FW1-~ ~ (R) ~ 1\~ ~ CfitI
-m)ti«A Cf11 ~ \Ri\ ~~ ~ ~ ~ ~ 3WPt iRl' iRm m 3Tftm , ~ ~ ~-;ffi
1{C1f:r-Tq 81 (tT)rmmtrn ~
r1'~~I<.It:11.
19.H <i; f:r-Tq II (t:t) <i; BT'l ';{.~ ~ ~ ~
, ftrn -crnfr,firfr ~ <t m <n1qrrn ~ 1?TII -.
(a) I undertake to relund the /9aye salary drawn during leave not due which would nol have been
admissible had F.R.81 (c) I Rule
I 11 (d) ollhe . Revised Leave Rules, 1933 not been applied, In the
, event01myvoLuntaryretirementOfresignat:onhom serviceat any timeuntilI earn hallpay leave
not less than the amount 01 l(!Qve not due availed 01 by me.

~ m~~m~
oa te , Signatureof applicant...........................
I J.r1tj~UI 3Tf~ Cfil rc.upJ~. rti\{1tf{~1
Remarks andlor recommendaJt?n of Controlling
~ the
Officer. .
m~Signature ..
~/Dale. ... ...... ~/Designation , ,..

~ qfr 3i j '"i~ {1I ~ <SITt

-q >rr1fUT
-~
CERTIFICATE REGARDING ADMISSIBLITY OF LEAVE
(~I~l.jr~d 31f~ cf; ;tc(~.{ ~ Ji~It1{glcfJl{WU)
(By Accountant General in the case f,f gazetted officers)
14. 1J1TIfum
~ ~ f; fcfi ~.. " ..........................

('ffi' """"" f<;1 ci; fu1:!, r1q Jilq~ ~

f.\<:tl1 cf; ~.fi1 " (~ q;1 ~) ~ t I
Gre Iilied tha t ... , (Name of Leave)

for 1rom (Perioo) to ;...

is admissible under rule , ...01 the... Rules

~~Signature .......................
~/Date ..".... ~/Designation ........
15. * ~1cf1r(t
c. ~ qffi m~l ~ ~ :-
* Orders 01the sanctioning authority:-
m8JtlSign.ature .
~/Date ......... ~/Designation .
*~" m~ ~ ~
Cf11 ~ ftIffiTIit m ~ ~ cm:1 3W~ em~ fureA1~ ~ wiJ ..c
~ m~ mm ~ 'tf'\ ~ ~ fcfim ~ "tR ~ ~ q;1 :mm -% 1fl ~ ~ ~ ~ em ~
flffi'm'it :-: ,,\
*11the applicant is drawing any com~nsatory allowance, the sanc!i":'nlngauthority should state
leaveon the expiry01leave he is likely'10returnto the same post or to another post carryingleave
allowance. .