1. Name of applicant:

2. Post held:

3. Department, office and section:

Institute of Physics Bhubaneswar

4. Pay:

5. House rent and other compensatory allowances drawn in the present post:

Not applicable

6. Nature and period of leave applied for and date from which required:

7. Sundays and holidays, if any, proposed to be prefixed/suffixed to leave:

8. Grounds on which leave is applied for:

9. Date of return from last leave, and the nature and period of that leave :

10. I propose do not propose to avail myself of LTC for the block years not applicable 2009- 2010- 2011- 2012- 2013- 2014- during the ensuing leave.

11. Address during the leave period: