Leave Format

(Up To One Month Duration Only)

(We assure a bright future)

S.No.:_________________

Date:______/______/_____

Reg. No.__________________________Name_____________________________________
Date of Birth______________________ Fathers Name_____________________________
Address
_________________________________________________________

_________________________________________________________
Pin________________Phone_________________________________
Module currently undergoing __________________________________________________
Mention the reason for taking leave______________________________________________
Expected date for resuming the course____________________________________________
Number of Days____________________ Leave From_______________ upto____________

DECLARATION BY THE CANDIDATE

Sir/Madam,
I have read and understood the instructions regarding taking leave/exam break. I know that if
the time period for break exceeds the specified duration, my registration will be cancelled
and I will have to register myself again by depositing the re-registration charges. I promise to
follow the rules and regulations of the institute and abide by them.
[Signature of applicant]

[Signature of the Parent/Guardian]

FOR OFFICE USE ONLY

Forwarded By:
Name :______________________________________ Signature :____________________

Leave Format
(Up To One Month Duration Only)
(We assure a bright future)
[Centre Manager]

Date: