पेज की सूची (सरकारी कर्मचारी फॉर्म)
  1. अर्जित अवकाश आवेदन फॉर्म
  2. फॉर्म 16
  3. फॉर्म 12(C)
  4. चिकित्सा प्रमाण पत्र (मेडिकल अवकाश)
  5. चिकित्सा प्रमाण पत्र (मेडिकल फिटनेस)
F.R. FORM
(See S.R. 3 below S.R. 74)
APPLICATION FOR LEAVE
(For both Gazetted & Non Gazetted Govt. Servants)
Note:- Items 1 to 10 must be filled in by all applicants whether Gazetted or Non Gazetted. Items 13 apply only in the case of Gazetted officers Items 14 & 15 apply in the case of Non Gazetted officers.
  1. Name Of Applicant
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  2. Leave rules applicable
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  3. Post Held
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  4. Department or Office
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  5. Pay
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  6. House rent allowance, conveyance allowance or other Compensatory allowances drawn the present post
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  7. Nature & period of leave applied for and date from which required
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  8. Ground on which leave is applied for
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  9. Date of return from last leave and the nature & period of that leave
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  10. Leave address, if granted
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  11. I undertake to refund the difference between the leave salary drawn during leave on average pay/commuted leave and that admissible during leave on half average pay/half pay leave, which would not have been admissible had the provision to F,R, 81(b)(II)M.B.F.R. 79(c) Rule 11(c) of the revised leave Rules 1933/Rule 14(c) of Madhya Pradesh Revised Leave Rules, 1934/Rule 963(c) of Rajasthan Service Rules, Not been applied in the event of my retirement from the service at the end or during the currency of the leave.
    Date:- _ _ _ _ _ _ _ _ _ _
    Signature
    &
    Designation
  12. Remarks and/or recommendation of the Controlling Officer.
    Date:- _ _ _ _ _ _ _ _ _ _
    Signature
    &
    Designation
  13. Report of the Audit Officer
    Date:- _ _ _ _ _ _ _ _ _ _
    Signature
    &
    Designation
  1. statement of leave granted to applicant previous to this application :----
    Name of leave In current year During past year Year
    (1)
    		 (2) (3) (4)
    Privilege/on average pay/Earned
    On average pay on M.C./ Commuted
    On half average pay/half pay
    Not due
    On Quarter average pay
    Extraordinary
    Total
  2. Certified that leave on average pay/earned leave for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ month and _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ days from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 201 to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 201 is admissible under _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    Date:- _ _ _ _ _ _ _ _ _ _
    Signature
    &
    Designation
  3. Order of the Sanctioning Authority ..............................................................................................
    Date:- _ _ _ _ _ _ _ _ _ _
    Signature
    &
    Designation