भारतीय �व�ान �श�ा एवं अनुसंधान संस्थान भोपाल

Indian Institute of Science Education and Research Bhopal

(Estb. by Ministry of Education, Govt. of India)

Office of Academic Affairs

Leave Application Form for Students
Leave Details
Type of leave*
For Academic leave Please fill the form along with Annexure-I (Attached below)
Leave availed during current Available leave balance
semester/year
Name Roll No.

Programme Department

Hostel Address Hostel No. Room No.

Leave Applied For No. of Days From To

In Case of Holiday Prefix Date(s) Suffix Date(s)

Purpose of Leave

Address During Leave

Contact No.

S. No. Course No. Instructor Instructor’s Signature

1.

2.

3.

4.

5.

6.

7.

8.
I understand that I have to carry out all academic activities like pre-registration/semester registration/SRS etc.
during the specified time window. There will be no make-up classes, labs or examinations and that it is my
responsibility to study on my own to make up for the academic sessions that I have missed/will miss.
Date:

Student’s Signature Thesis Supervisor Course Instructor/ Faculty Advisor#

(If Applicable) ( For Student Tutor)/(for 1st & 2nd Year UG Student’s)

Dealing Assistant Convener, DUGC/DPGC

Department Office
Permitted/Not Permitted

Dean/Associate Dean
Academic Affairs
Leave application should be submitted in the Office of Academic Affairs at least 10 working days in advance
and should proceed only after sanction of the leave.
# Course Instructor may ask the student for a substitute tutor, if required.
Note: For Academic Leave Please fill out the Annexure-I
 (Annexure-I)
Academic Leave for Research Work

To,
DOAA

Subject: Request for academic leave to visit the …………………………… <Institute/Event> for
……………………………………………………………………………… <Purpose of Leave>.

Dear Sir/Madam,
I, ……………………………<name>…………..…(<roll no>) would like to visit to
…………………………… for……………………………………….……… < Purpose of Leave>,
this is to request for your kind permission for the same, necessary details are provided below:
Details of Host Institute:

Name & Designation of host PI/Researcher: ………………………………………………………

Address of Institute/Organization: …………………………………………………………………

Country: India Abroad

Details of Ph.D. Thesis Supervisor from IISER Bhopal: ……………………………………………

Duration of visit: from………………………. To…………………………………..

Details of Financial Assistance/Stipend received/Committed:

Expenses covered by host

Particulars Amount
Institute (Yes/No)
Travel
Accommodation
Stipend/Fellowship
Contingency
Others

Recommendation of supervisor for the payment of fellowship (PG Manual 2020 clause number 15.2)
during the period of the academic leave: Yes NO

Sincerely,

Signature and name of the student Supervisor

Date:

DPGC HoD

Encl: Offer/Invitation letter from the external Institution/Agency/PI/Researcher

Note: Please submit this form along with the duly filled academic leave application form.