Employees' State Insurance Corporation

Form 1 (Rule 14 of FR & SR Part-III Leave Rules)

RO - Ahmedabad
APPLICATION FOR LEAVE OR EXTENSION OF LEAVE

Request No. :LV0001310512

1.Employee no. / Employee Name / : 138185 / Jaydeep Natvarlal Aagja / Assistant

Designation

2.Request For : Self

3.Leave Type : Casual Leave

4.Leave Reasons : NA

5.Family Details ( Name - Relation) : NA

6.Event Date : NA

7.Document Check : No

8.Availing Encashment : No

9.Encashment Days - Amount : 0 - 0.0

10.Available Balance : 5.00

11.Leave no. of Days : 1.0

12.Is Extended : No

13.Extended Date - Days : NA - NA

14.From Date - Part of Day : 01/11/2019 - Full Day

15.To Date - Part of Day : 01/11/2019 - Full Day

16.Prefix Date - Day : NA

17.Suffix Date - Day : NA

18.Leave Combined : No

19.Preceeding Combined Leave : NA - 0

(Req. No. - No. of Days)

20.Succeeding Combined Leave : NA - 0

(Req. No. - No. of Days)
21.Address of Employee : : 56/219 E Colony "Near Ambar Cinema" Ahmedabad 'Ahmedabad'
Gujarat 380024

22.Notings : : Kindly approve above bill.

Place : RO - Ahmedabad Signature :

Date : 08/11/2019

22.Remarks and /or recommendation of the Controlling Officer

Competent Authority Signature :

Competent Authority Name :

Designation :

Date :

CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE

23. Certified that Casual Leave for 1.0 days from 01/11/2019 to 01/11/2019 is admissible under Rule

............................ of the Central Civil Services (Leave) Rules 1972.

Place : RO - Ahmedabad Signature :

Date : 08/11/2019

24.Order of the authority competent to grant leave

Competent Authority Signature :

Competent Authority Name :

Designation :

Date :

If the applicant is drawing any compensatory allowances, it should also be indicated in the orders on the expiry of

leave, the Government servant is likely to return to the same post or to another post carrying similar allowance.