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(See Rule 175)

NOTE: Items 1 to 9 must be filled in by all applicants whether gazetted or non –

gazetted. Item 12 applies to Gazetted Officers. Items 13 and 14 apply only to
Non-Gazetted Officers.

1. Name of the applicant

2. Leave rules applicable i.e.,

M.S.Rs/B.C.S.Rs/ F.R.s (Madras
Central)/ H.C.S.Rs, K.C.S.Rs.

3. Post held

4. Deptt. Office & Section

5. Pay

6. House rent allowance,

conveyance allowance, or other
compensatory allowances drawn
in the present post

7. Nature and period of leave

applied for and from which

8. Ground on which leave is applied


9. Date of return from last leave and

the nature and period of that

2[9 (a) Address during leave

3[10. XXX

1. Substitute by No.FD 151 SRS 61, dated 5/8.1.1962

2. Inserted by FD 229 SRS 71, dated 25.1.1972 (wef 24.2.1972)
3. Deleted by No.FD 91 SRS 78, dated 8.2.1980 (wef 28.2.1980)
11 Remarks and/or
recommendation of the
controlling officer

Date: Signature:
12 Report of the Audit Officer

Date: Signature:
13 Statement of leave granted to
applicant previous on this application
Nature of leave in current year During past year

Privilege/Earned Furlough on
average salary/ on average pay
on M.C./Commuted on half
average pay/half pay
Not due

14. Certified that Privilege leave
Earned Leave
month and………….. days from ………………….. to is admissible under……… of

Date: Signature
15.* Orders of the sanctioning authority

Date: Signature:
*If the applicant is drawing any compensatory allowance, the sanctioning authority
should state whether on the expiry of the leave he is likely to return to the same post or
to another post carrying a similar allowance].