GOA INSTITUTE OF MANAGEMENT

SANQUELIM, GOA 403 505

LEAVE REQUEST FORM

Date: _____________

Name: ______________________________

Mob. No.: ____________________________

Roll No: _________________ Section: ______

No. of days Leave requested: _______

Term: _____ Batch: ________________

From: ________________ To _______________

Reason: ____________________________________________________

Name of the Courses you will be absent during the Leave period:

Session No. Name of Course Faculty Signature