Indian Institute of Science Education and Research

Thiruvananthapuram
Academic office

STUDENT LEAVE APPLICATION FORM

1 Name of student with Roll No.

2 Home Address
(Phone no.
/Email ID)

3 Contact addresses during

Leave period
(For in case of
emergency) Ph. No
4
Purpose of Leave (Please specify).

5 Name of Faculty Advisor in case of MS student

6 Name of Supervisor/Guide in case of Ph. D student

7 Duration of Leave from Date: To Date: Total days of

Leave Time: In Time: Leave
8 Latest mess bill paid for Amount Date of pay
the month
9 Hostel Name Room No. Discount
from Mess
bill( No. of
Days >5)
*Senior BS-MS Students and PhD students should also get the approval from the Coordinator of the respective Schools as given below.

Signature of the applicant with Date

Forwarding Authority with comments if any

Faculty Advisor/Guide Coordinator of the School Hostel Warden

Approving Authority with comments if any

PhD/BS-MS Coordinator/Dean( Academics )

Information received Signature of Academic-office-in-charge

Mess Information Slip (Below details must be filled by the student)

Name and Rollno. of the student Duration of Leave from Total days of Leave
Date: To Date:
Leave Time: In Time:

Signature of Academic-office-in-charge Signature of the Mess Contractor