Revised on June 30, 2011 LEAVE REQUEST FORM Date: PRM: First / Second Year Term:... Name:..

Roll No.: To: PRM Coordinator through Course Instructor

I will not be able to attend the classes as per the details given below: No. of Sessions to be missed No. of sessions already missed in the course Sign. of the Course Instructor Remark from Course Instructor (if any)

Date

Course

Reason for Absence

The leave request form must be submitted before going on leave in PRM office. Kindly fill date wise and session/s wise details in the leave application form separately. . Signature of Student If leaving campus/hostel for overnight: Number of day/s From/On (Date):..to . Signature of Warden Date: _________________________________________________________________________________________________ FOR OFFICE USE ONLY Received by PRM office on: Penalty details: 1. Half Penalty (0.05) 2. Full Penalty (0.10) 3. No Penalty
(Only in special cases)

Signature:.

Signature of PRM Coordinator