THE SECOND SCHEDULE(SEE RULE 3 (II)

APPLICATION FOR LEAVE OR FOR EXTENTION OF LEAVE

1. Name of the applicant :

2. Post held :

3. Deptt. /Office, Section :

4. Pay :

5. House Rent & other compensatory :allowance & date from which at present post

6. Nature & period of leave : applied for & date from whichrequired

7. Sunday & Holiday if any :prefixed to leave

8. Grounds on which leave is :

9. Date of return from last leave :& nature & period of that leave

10. I propose / do not propose to :avail myself of LTC for the block Year …N/A……… duringthe ensuing leave

11. Address during leave period :

Signature of Applicant(with date)

12. Remarks & recommendations of theControlling officer :

(Signature)With date & designation.