INDIAN INSTITUTE OF MANAGEMENT ROHTAK

STUDENT LEAVE APPLICATION FORM

Programme and Batch No.: IPL AND 01

Term: III

Age: 19 (For IPL Only)

Name: YASHICA DHAWAN

Roll No.: ____IPL01126______________

No of Days Leave Required: 1 (one)

From: 5th June To: 5th June

Purpose of Leave: Family Function
Contact details of Parents/Other people with whom spending leave:__Ritu Dhawan
9910539198_________________________
Self-certification on academic and institute specified Activity(use sub para below that is applicable
and score out others)

a) Certified that I will miss 0(zero) 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 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:1/6/2022

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