INDIAN INSTITUTE OF MANAGEMENT ROHTAK

STUDENT LEAVE APPLICATION FORM

IPL AND 01
Programme and Batch No_________________Term______________Age_____________(For
III 18 IPL Only)
NITIKA DHEER
Name__________________________________Roll IPL01080
No. ______________________________________
1(ONE) 5TH JUNE 5TH JUNE
No of Days Leave Required_______________From_______________________To_________________
Purpose of Leave______________________________________________________________________
FAMILY FUNCTION

____________________________________________________________________________________
____________________________________________________________________________________
MINAKSHI DHIR, 9303093427
Contact details of Parents/Other people with whom spending leave_______________________________

Self-certification on academic and institute specified Activity(use sub para below that is applicable
and score out others)
0(ZERO)
a) Certified that I will miss______________No of classes.
b) Certified that I have no classes/academic activity during the period for which I have applied for
leave.
--------
c) Certified that I am part of ________________________activity specified by the institute/not part
of any other activity specified by the institute during the period of intended leave.
d) Certified that I have requested this leave for medical reasons which has been verified by the
doctor at the institute (student should enclosed medical certificate from the Institute’s doctor).
e) Certified that it is Duty Leave certified by my Programme Chair and Dean (certified to be
enclosed).
f) Certified that I am fully aware about the implications of the academic absence as per rules stated
in the Programme handbook.

I take full responsibility for my own conduct while on leave.

Date 2/6/2022 Signature of Student

For Office Use Only

Verification, Remarks and Signature of the Programme Officer __________________________________

_____________________________________________________________________________________

Date: Signature (AO)

Date: Remarks and Signature of IPL Chair

Date: Remarks and Signature of student Affairs Office

Approved/Not Approved

Date : Signature of OSD/Approving Authority