(FORM 1)

[See Rule 14]

Application for leave or for extension of leave

1. Name of applicant:
2. Post held
3. Department office and section

[tSe
Department office and sectionA / ' RJ:S
. •tj
p t eeo on f;,r feev,,or tcr ,,r.tcnsro11 of /1Jovo
o
1 Nameof applicant
2. PO$l hald
3. Departm@nt ol'l'ice and sec on
4 Pay
5. House-rent and other compensatory
gllowaneGs drawn in tl'le present post
6. Natureand period of leave
applied for.and date from
which required
7 Sundays and hol diys,if ny,proposed ..
to be Pl'lfixedlsuffixed to leave
8, GroundaonWhich leave ls appliedfor
9. Date of return.from last !Nve, a.ndthe.
nature and period ofthatleave
10. · Ipropo&e/do not propose to
avail myselftoleave
travelconcassion!or the block
years.....................during the
ensuing leave
11. Address during leave period
12. Inthe event.of my resignationor voluntary retirement from service,Iundertake I ::> refUnd-
(i) the difference betweenthe leave salary drawnduring commuted leave an :I :hat admissibleduring
the
half-pay.leave which would not been adml ible hadsub-rule (1) of rule 3 ) 10t been
&PP.lied ;
(ii) the leavesalary drawn during leave notdue whichwouldnot have been ac n assible hed sub-rule
{1) or
rule 31not beenapptied.

. , Slgr:1 ure of the applicant

. (With date)
13. · Reqtks and/or recommendation of the Controlling Offlcer.

SI;11ature (with date}

 Certificate regarding admissibility of leaV!*
. (By Audit Officer in case ot Gazetted Officer)
. . . . . . . of lea •
14. Cettiffed that ...................................................................{nature ve) fl 1r
(period)..........................
. from.........,....'..................to ............................ ... ......Is admissible und ·
ru"ki.............................
ofthe Centnal CMIService (L) Rules, 1972.
·1
Sig 1t ire (with date)
C esi!Jlatlon .

15. Order.I.of the a;rthorily competent to grant

lffve.

Slgm 1t ire (With d81t}

C esignatlon.