APPLiCATION FOR LEAVE

SR - 1
Note:- Items t to 11 must be filled ill by all applications whether Gazetted
or Non - Gazetted.
I. Name of applicant :--
2. Leave Rules applicable
3. Post held j-

4. Department, Office & section

5 Pay:-
6. House rent alice, convoyance allces :-
or other compensatory allccs, drawn
in t he present post.
7. Nature & period of leave applied for
& date from which required.
8. Sunday & Holidays, if any proposed to be
prefixed / suffixed to leave.
9. Ground on which leave and the nature :-
10. Dale of return from last leave and the ;-
nature and period of that leave.
II. I propose / donot propose to avail myself of
leave travel concession for the block year.
......................... during the ensuring leave,
12. (a) I undertake the refund the diflerance between
the leave salary during leave on average pay/commoted leave
and that admissible during leave on half average pay I half
pay leave which would not have been admissible had the
provision FR 81 (b) (ii)!rule II((iii) of the revised Leave
Rules 1933 not been applied iu the even of Illy retirement
from service at tbe end of or due in the current of leave.
(b) 1undertake to refund the leave salary drawn during •• leave not due"
which would not have been admissible had FR-81 (c) Rule n (d) of the revised
leave Rule 1933 not 'been applied in the even of my voluntary rctiresent from
service at the end or during the currency of the leave.
lc) F\dl address while on leave.
Signature of applicant ( with dale)
13.' Remarks and I or recommendation or the controlling Officer.

Signature ( with date).

CERTIFICATE REGARDING AMfSSIBILlTY OF LEAVE
( By Accountant General in case or Gazetted Officer)
14 Certified that _ for .
Lys frolll............. to . admissible .

15. *
under Rule
Orders of the sanctioning authority.
of the _.._ Rules.

SIGNATURE & DESIGNATIONI

In the applice nt is drawing any compensatory allowance sanctioning authority
should state whether on the expiry of leave be is likely to recommended to the
some post or the another post carrying a similar allowance.