Application for leave

Note- Items I to 9 must be filled in by applicants whether gazetted or non-gzetted

item 12 applies only in the case of non-gazetted officers
Ttem 13 and 14 applhy in the case
of non-gazetted oficers.

1. Name of applicant
Leave Rules applicable
2. RevisedLeaveRule,1934
3. Post held

4. Department or office

5 Pay ****

. House rent allowance, conveyance allowance or

Other compensatory allowances drawn in the
Present post. ***

1. Nature and period of leave applied for: .

8. Ground on which leave is applied for..

9. Date of return from last leave, and the
Nature and period of that leave.

leave on
10. I undertake to refund the difference between the leave-salary drawn during
admissible during leave on half average pay/ half pay leave,
average pay/commuted leave and that
which would not have been ad sible had the proviso to F. R. 18 (b) (ii)/ Rule 13(cXii) of the
Revised Leave Rules, 1934 not been applied in the event of my
retirement from service at the end
or during the currency of the leave..

Signature of applicant
Date.... Address after retirement/Leave address

Remarks and/or recommendation of the Controlling Officer-

° ° ° * * ° * * * * ° * * *

*°*°*°******°°°°*°**°******°°*°*°****°*°***

*******4o*°*°
°******°*°*°***
***

Signaturee
Date....
*********i**4s*********** Designation
12. Report of Audit Officer *°°*****°**°*******************|

Signature
Date... *********

Designation