Employees' State Insurance Corporation

Form 1 (Rule 14 of FR & SR Part-III Leave Rules)

ESIC Dispensary - Jangpura

APPLICATION FOR LEAVE OR EXTENSION OF LEAVE

Request No. :LV0002422649

1.Employee no. / Employee Name / : 148168 - Promila Rani - Pharmacist(Entry Grade)

Designation

2.Request For : Self

3.Leave Type : Earned Leave

4.Leave Reasons : NA

5.Family Details ( Name - Relation) : NA

6.Event Date : NA

7.Document Check : No

8.Availing Encashment : No

9.Encashment Days - Amount : 0.00 - 0.0

10.Available Balance : 154.00

11.Leave no. of Days : 4.0

12.Is Extended : No

13.Extended Date - Days : NA - null

14.From Date - Part of Day : 03/04/2023 - Full Day

15.To Date - Part of Day : 06/04/2023 - Full Day

16.Prefix Date - Day : NA

17.Suffix Date - Day : NA

18.Leave Combined : No

19.Preceeding Combined Leave : NA - 0

(Req. No. - No. of Days)

20.Succeeding Combined Leave : NA - 0

(Req. No. - No. of Days)
21.Address of Employee : : H. No. - 112, V.P.O. "Bijwasan" South West Delhi 110029
9910008770

22.Notings : : i have some work.kindly approve my leave

Place : ESIC Dispensary - Signature :

Jangpura
Date : 27/03/2023

22.Remarks and /or recommendation of the Controlling Officer

Competent Authority Signature :

Competent Authority Name :

Designation :

Date :

CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE

23. Certified that Earned Leave for 4.0 days from 03/04/2023 to 06/04/2023 is admissible under Rule

............................ of the Central Civil Services (Leave) Rules 1972.

Place : ESIC Dispensary - Signature :

Jangpura
Date : 27/03/2023

24.Order of the authority competent to grant leave

Competent Authority Signature :

Competent Authority Name :

Designation :

Date :

If the applicant is drawing any compensatory allowances, it should also be indicated in the orders on the expiry of

leave, the Government servant is likely to return to the same post or to another post carrying similar allowance.