Name : _________________________________________________

Roll – No. : ______________________________________________

Term : ____________________ Section: _____________________

S.No Course Classes Missed Reason Enclosure Classes missed Classes missed Classes missed after Comments
. Name (Leave applied for) No./Medical before the leave during the leave the leave period (For office
Certificate No. period period only)
Session No.:
1 Date:
Time:
Session No.:
2 Date:
Time:
Session No.:
3 Date:
Time:
Session No.:
4 Date:
Time:
Session No.:
5 Date:
Time:
Session No.:
6 Date:
Time:

Signature of the Participant Signature of the Approving Authority