2395
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 :
3. Post held :
4. Department or Office :
5. Pay :
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
Designation: .............................................................
Designation: .............................................................
Extraordinary
______________________________________________________________________________ rule.
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)
3. SALARY :
5. ON WHAT GROUND :
________________________________
SIGNATURE OF GOVERNMENT SERVANT
OFFICE REPORT
________________________________
RECOMMENDATION OF HEAD OFFICE &
ARRANGEMENT PURPOSE FOR WORK.
___________________________
SIGNATURE & DESIGNATION OF
SANCTIONING AUTHORITY.
GOVERNMENT OF WEST BENGAL
OFFICE OF THE SUB-DIVISIONAL LAND & LAND REFORMS OFFICER
SILIGURI
He / She is further permitted to be away from the office during the leave period,
Sri / Smt. ________________________________________, will look after the works period,
Certificate that aforesaid incumbent was in the same post before proceeding on leave.
5. Order Book.
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.
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