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INDIAN INSTITUTE OF MANAGEMENT AHMEDABAD

TWO YEAR POST GRADUATEPROGRAMME IN MANAGEMENT

APPLICATION FOR LEAVE


l. Namc MAYAN)k NARA)tU RollNo: 17/88

2. Year pc, P 1/11 Section :

3. Dorm No.. MobileNo.: 0g 23)

4. a. Leave requested from

a. No. of days 2
5. Reason for Leave
(If medical. kindly get Endorsement fe ver-
from the Institute Doctor in the
prescribed form

6. Course details

List all the courses of Total no. of Date(s)of Class(es) No. of classes Total no. of
clmssesmissed sessions in the classes missed missed earlier missed / to be classes missed
course missed this
time

14 Il -q;17; 12-9-17 2 2
(1-3-17, N one 2

15 -4-17; rub n e 2 2

Travel Schedule

Date. 14 9.17 Chaiperson-PGP / PGP Office


(Signature) (Signature)

PROFORMAFOR MEDICALLEAVE

I have examined Mr. / NJ


a PGP I / Il student and found that he / she is suffering from
He / She has been advised complete rest day/s with effect from

Sig titut tor


12.9.1>

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