DISTRICT INSTITUTE OF EDUCATION AND TRAINING : LAWNGTLAI
LEAVE APPLICATION FORM FOR STUDENT
A. PARTICULARS
1. Name of student : _______________________________________________________
2. Roll. No.: __________ 3. Semester: __________ 4. ID no.: __________________
5. Mobile No. of Parents: ___________________________________
B. LEAVE DETAILS
1. Leave applied for ________ days, w.e.f. __________________ to __________________
2. Total leave already taken: ________________ of working days.
3. Places of stay during leave: ________________________________________________
4. Speci c reasons of leave request :
(a) ___________________________________________________________________
(b) ___________________________________________________________________
(If leave is require due to illness, the application shall be supported by a medical certificate issued
by a Registered Medical Practitioner.)
C. DECLARATION
(a) I understand that it is my responsibilty to maintain 80% attendance for appearing in the
Semester Examinations and this leave request will not come in the way of completing
attendance requirement.
(b) I understand that disciplinary action shall be taken against me, if I will not return aer
completion of leave.
Date : _______________________
Mobile No. : _______________________ (Full signature of student)
Recommendations of Discipline Incharge
________________________________
________________________________
(Signature of Discipline Incharge with date)
