डा बी आर अम्बेडकर राष्ट्रीय प्रौद्योगिकी संस्थान जालन्धर-१४४००८, पं जाब (भारत)

Dr B R Ambedkar National Institute of Technology Jalandhar-144008, Punjab (INDIA)

lUnHkZ la[;k@Ref No.: ______________ fnukad@Date: ___________ih,p@PH-21-A
Nk= vodk”k izi=@STUDENT LEAVE FORM
Hkkx&, ¼”kks/kkFkhZ gsrq½@Part-A (For Scholar):
“kks/kkFkhZ dk uke@Name of the Scholar: vuqØekad@Roll No.
foHkkx@dsUnz@Department/Center: l=@Semester

vkosfnr vdk”k dk izdkj o vof/k@Type and Period of Leave Applied for: ls@From rd@To fnuksa dh la[;k
CL Medical Leave RH No. of Days

vodk”k dk dkj.k@Reason for Leave:

vodk”k ds nkSjku lEidZ dk irk o lEidZ la[;k irk@Address lEidZ la[;k@Contact
Contact address and number during Leave: No.

vodk'k dh O;oLFkk ¼;fn dksbZ gks½@Leave arrangements (If any)

ls@From rd@To fnuksa dh la[;k@No. of Days
NqfV~V;k¡@Holidays iwoZ;kstu@Prefix
vuq;kstu@Suffix
vofèk gsrq eq[;ky; NksM+us dh vuqefr vko';d gS ls@From rd@To
Station Leave permission required for the period
lgk;d nLrkost+ layXu djsa ¼vU;@fpfdRlk vodk'k ds ekeys esa —i;k fpfdRlk çek.ki= rFkk
LokLF; çek.ki= layXu djsa½@Supporting documents attached (In Case of Other
Leave/Medical Leave Please attach Medical Certificate & Fitness Certificate)
Nk=kokl fuoklh ¼gk¡@ugha½@Residing in Hostel (Yes/No) Nk=kokl la[;k@Hostel No: dejk la[;k@Room No.:
¼;fn gk¡] Nk=kokl fooj.k miyC/k djsa@If yes, provide the Hostel Details)
dksbZ vU; lwpuk@Any Other Information

“kks/kkFkhZ dk gLrk{kj@Signature of Scholar

vuq”kalk@Recommendation: vuq”kaflr@Recommended xSj vuq”kaflr@Not Recommended

i;Zo{s kd dk gLrk{kj@Supervisor(s) Signature

Hkkx&ch ¼dsoy dk;kZy iz;ksx gsrq½@Part-B (For Office use only):
Ø-la- dSys.Mj o’kZ esa miyC/k dqy vodk”k ¼30½ vodk”k ¼आधार½
S. No. Total Leave available in calendar Year ¼30, CL-8, RH-2, ML-20) Leaves (Ground)

(a) yh xbZ vodk”k@Leave availed

(b) miyC/k “ks’k@Balance Available
(c) pkyw ekg esa miyC/k vodk”k@Leave availed in current Month
(d) vodk'k mijkUr fcuk lkgp;Z dk vodk”k
Without Stipend after availing leaves
vodk'k iqfLrdk ds i`"B la[;k ----------------------------------------------------- Øekad ----------------------------------------------------------- ij vafdr
Entered in the Register Page No. …………………………………. Sr. No. ………………………………………….
* lR;kfir fd;k tkrk gS fd Hkkx&ch ds lkeus mfYyf[kr fooj.k foHkkx ds fjd‚MZ ds vuqlkj Øe esa gSaA
Verified that the particulars mentioned against Part-B are in order as per the record of the Department.

O;ogkj lgk;d dk gLrk{kj

Signature of Dealing Assistant
fu.k;Z@Decision: vodk”k vuqeksfnr@Leave sanctioned xSj vuqeksfnr@not sanctioned

foHkkxk/;{k dk gLrk{kj
Signature of Head of Department

(This form is to be retained in department office for records)