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W.B Form No.

2395

APPLICATION FOR LEAVE

Note: It is to must be filled in by all applicants, whether Gazetted or non-Gazetted. Item 12 applies
only in the case of Gazetted Officer. Item 13 & 14 apply only in the case of Non-Gazetted Officers.

1. Name of Applicant :

2. Leave Rule Applicable :

3. Post held :

4. Department or Office :

5. Pay :

6. House allowance, Conveyance :


Allowance or other Compensatory
Allowances drawn in the present
Post.

7. Nature & Period of Leave :


Applied & date from which
Required.

8. Ground on which leave :


Is applied for

9. Date of return from last :


Leave and nature and period
Of that leave

10.(a) I undertake to refund the difference between the leave salary drawn leave on average pay/
commuted leave and that admissible during the leave on half average pay/half pay leave.

Which would not have been admissible had the provision to Rule 184(b) & Rule 172(c).

Of the WBSR Part-I not been applied in the event of my retirement from Service at the end
or during the currency of the leave.

(b) I undertake to refund the leave salary drawn during leave not due which would not have
been admissible had the Rule 184(c)/173 if WBSR Part-I not been applied in the event of my
retirement from serviced at the end or during the currency of the leave.

Date: / /201
Signature of Applicant
11. Remarks/Recommendation of :
Controlling Officer

Date: Signature: .................................................................

Designation: .............................................................

12. Report of the Audit Officer :

Date: Signature: .................................................................

Designation: .............................................................

13. Statement of leave granted to applicant previous to this application.

Nature of Leave In Current Year During Last Year Total


Privilege/On Average Pay/
Earned/On half Average
On Half Average Pay/On MC/
Commuted /On Half
On Half Average Pay/Half Pay

Not Due/On Quarter

On Quarter Average Pay

Extraordinary

14. Certified that leave on ________________________ average pay. For __________________

______________________________________________________________________ earned leave.

____________________________________________ months __________________________ days

from __________________________ to ________________________ is admissible under article of

______________________________________________________________________________ rule.

Date: Signature: .................................................................

Designation: .............................................................

If the application is during any compensatory allowances, the sanctioning authority should state
whether on the expiry of leave he is allegedly to return to the same post to another post is carrying
similar with allowance.
APPLICATION FOR LEAVE
(Non Grazetted Officer)

1. NAME OF THE APPLICANT :

2. DUTY ON WHICH EMPLOYED :

3. SALARY :

4. NATURE AND PERIOD OF


LEAVE ASKED FOR :

5. ON WHAT GROUND :

6. ADDRESS WHERE ON LEAVE :

________________________________
SIGNATURE OF GOVERNMENT SERVANT

OFFICE REPORT

________________________________
RECOMMENDATION OF HEAD OFFICE &
ARRANGEMENT PURPOSE FOR WORK.

The leave applied for is admissible


Under Rules & may be granted.

___________________________
SIGNATURE & DESIGNATION OF
SANCTIONING AUTHORITY.
GOVERNMENT OF WEST BENGAL
OFFICE OF THE SUB-DIVISIONAL LAND & LAND REFORMS OFFICER
SILIGURI

EARNED LEAVE SANCTION ORDER

Order No. /SDLLRO-SLG/17-18 Date: / /2018

Sri /Smt. _________________________________________________, attached to the Office of the


____________________________________, is hereby granted Earned Leave / Commuted Leave /
Maternity Leave for _______ ( _____________________ ) days from _____ / _____ / 2018 to
____ /____ / 2018 under Rules 169, 173, 199 of the W.S.S.R. Part- I with permission to prefix
_______________________ and affix __________________________ with his / her leave.

He / She is further permitted to be away from the office during the leave period,
Sri / Smt. ________________________________________, will look after the works period,

Sri / Smt. ________________________________________ during the leave period.

Certificate that aforesaid incumbent was in the same post before proceeding on leave.

Sub- Divisional Land & Land Reforms Officer,


Siliguri.

Memo No. /(SDLLRO-SLG/17-18 Date: / /2018

Copy forwarded to:

1. Sri /Smt. ____________________________________ for information.

2. B.L& L.R.O./ S.D.L.& L.R.O./S.M.C.A.(LR)/ T.A. Section, __________________ for information.

3. Sri /Smt. ____________________________________ for information.

4. R.I. Office, ___________________________________ for information.

5. Order Book.

Sub- Divisional Land & Land Reforms Officer,


Siliguri.
GOVERNMENT OF WEST BENGAL
OFFICE OF THE SUB-DIVISIONAL LAND & LAND REFORMS OFFICER
SILIGURI

CHILD CARE LEAVE ORDER

No.__________/SDLLRO-Slg/17-18 Date: / /2018

Smt.__________________________________ , attached to the Office of the


__________________________________________ , is hereby granted Child Care Leave for
_______ (____________) days from _______________ to ______________in terms of Finance
Department Order 1364/F-P dated 15.02.2012 and on verification of birth certificate D/O or S/O
Smt.______________________________________

She is further permitted to be away from the office during the leave period. Shri/Smt.
_____________________________________ , ________ is the leave substitute to work for the
absentee.

Certificate that aforesaid incumbent would have continued in the same post but for
proceeding on leave that the period of leave will count for increment.

Sub-Divisional Land & Land Reforms Officer


Siliguri

Memo No. _________/SDDLRO-SLG/17-18 Date: / /2018

Copy forwarded to:

1. The Directorate of Land Records & Survey,& Joint Land Reforms Commissioner,
35-Gopal Nagar Road, Kolkata-27.
2. The District Land & Land Reforms Office, Darjeeling.
3. Treasury Officer-II, Siliguri.
4. Bill Clerk
5. Smt.______________________________.
6. Sri/ Smt____________________________
7. Order Book
8. Service Book Clerk for taking necessary action.
9. Office copy / File

Sub-Divisional Land & Land Reforms Officer


Siliguri

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