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LWA application govt of kerala
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PROFORMA TO BE APPENDED WHEN PROPOSALS FOR SANCTIONING LEAVE WITHOUT ALLOWANCE TO TAKE UP EMPLOYMENT ABROAD/WITHIN THE COUNTRY/ACCOMPANY SPOUSE ABROAD WITHIN THE COUNTRY ARE FORWARDED TO GOVERNMENT
1 Name and designation of the applicant :
2 Institution in which the applicant is working :
3 Date from which leave is required :
4 Duration of leave :
5 Purpose of leave :
6 Whether the appointment of the applicant in the department is regular :
7 Total period of regular service put in by the applicant in the Department on the date of application and the date from which his/her continuous service begins in the department :
8 Whether there is any disciplinary action pending : No
9 Whether there is any bonded obligation or contractual obligation : No
10 Whether there is any liability outstanding : No
11 Whether the applicant has been sanctioned any advances such as HBA/MCA etc : No
12 Whether the applicant has been sanctioned leave for the same purpose earlier and if so furnish the details : No
13 Whether the applicant has been sanctioned leave without allowances earlier for any purpose : No
14 Whether any relaxation of rule is necessary to sanction leave : No
15 Whether you are convicted that suitable substitute arrangements are easily available and if so, whether a live list of candidates for appointment is available with PSC : Yes
16 Whether leave is recommended or not : Recommended
17 Leave address of the applicant in India :
18 Leave address of the applicant in abroad :
19 Any other relevant points to be brought to notice of Government
Signature of Head of Office Counter signature
(Page-2)
CHECK LIST
1 Name and designation of applicant with full address :
2 Date of birth :
3 Date of commencement of continuous service :
4 Date of retirement :
5 Period of LWA applied for and date from which applied for :
6 Purpose of leave :
7 Whether fresh application or extension, if extension whether application in time : Fresh
8 Details of LWA taken previously for the same purpose :
9 Date of receipt of application by Head of Office :
10 Date of recommendation by Head of Office :
11 Date of counter signature by the controlling officer :
12 Date of dispatch of leave application :
13 Whether necessary certificates declarations are furnished with the application :
14 a) Lien certificate from the manager :
b) Departmental NOC : Yes
c) Declaration regarding liability : Yes
d) Declaration regarding non involvement of antinational activities : Yes
15 Service Book of the employee with upto date entries : Yes
16 Remarks :
Signature of Head of Office Counter signature
-3-
DECLARAION
I , ………………………………………………………… do hereby declare that I shall not leave India to take up employment abroad without prior permission of Government of Kerala.
Place: Signature
Date : Designation
Office:
Signature of Head of Office
Counter Signature by sanctioning Authority
-4-
DECLARAION
I , ……………………………………………………… do hereby declare that
1. I have no bonded obligation to serve the department
2. I also declare that no disciplinary action is pending against me
3. It is also declared that I will not entertain in any propaganda which is against the Government of India
4. I will return to duty as and when the Government of Kerala call for me back
5. I also undertake that I will abide by all conditions regarding the sanction of leave now applied for.
Place: Signature
Date : Name:
Designation
Office:
Signature of Head of Office
Counter Signature by sanctioning Authority
-5-
DECLARAION
I , …………………………………………………………, …………………………………..(designation) do hereby declare that I have not been convicted by any court of Law for any offence including moral turpitude
Place: Signature
Date : Name
Designation
Signature of Head of Office
Counter Signature by sanctioning Authority
-6-
DECLARAION
I , …………………………………………………………, …………………………………..(designation) …………… ………… ……….. . …….. …….. ……….(office) do hereby declare that no disciplinary action is pending against me.
Place: Signature
Date : Name
Designation
Signature of Head of Office
Counter Signature by sanctioning Authority
-7-
DECLARAION
I , …………………………………………………………, …………………………………..(designation) …………… ………… ……….. . …….. …….. ……….(office) do hereby declare that I have not availed any loan or advance from Government and no liability is outstanding against me.
Place: Signature
Date : Name
Designation
Signature of Head of Office
Counter Signature by sanctioning Authority
-8-
DECLARAION
I , …………………………………………………………, …………………………………..(designation) …………… ………… ……….. . …….. …….. ……….(office) do hereby declare that I am fully aware of the fact that the leave without allowances now applied for if granted will not be counted for any service benefits including pension and will be recorded as such in the service book. It is also declare that I am prepared to abide by all terms and conditions in Appendix XIIA Part I KSR
Place: Signature
Date : Name
Designation
Signature of Head of Office
Counter Signature by sanctioning Authority
DECLARAION
I , …………………………………………………………, …………………………………..(designation) …………… ………… ……….. . …….. …….. ……….(office) do hereby declare that I will abide by the Rules in Appendix XII A of G.O.(P) No 953/86/Fin dt 27/12/1986 and its subsequent amendments.
Place: Signature
Date : Name
Designation
Signature of Head of Office
Counter Signature by sanctioning Authority
-9-
DECLARAION
I , …………………………………………………………, …………………………………..(designation) …………… ………… ……….. . …….. …….. ……….(office) do hereby declare that I will abide the conditions laid down in Appendix XII Part I KSR
Place: Signature
Date : Name
Designation
Office
Signature of Head of Office
Counter Signature by sanctioning Authority
CERTIFICATE
Certified that no disciplinary action is pending against Sri……………. ……… .. …………….. ……….., ……………… … … …… …… …….. ……. designation)………. ……………… ………………… ………………….. .(Office) who have applied for LWA for 5 years.
Place Signature of Head of Office
Date :
Counter Signature by sanctioning Authority
CERTIFICATE
Certified that no liability is outstanding against Sri……………. ……… .. …………….. ……….., ……………… …… …….. ……. designation)………. ……………… ………………… ………………….. .(Office) who have applied for LWA for 5 years.
Place Signature of Head of Office
Date :
Counter Signature by sanctioning Authority
-10-
Form No 13
APPLICATION FOR LEAVE
(Rule 113, Part – 1)
Note: Items 1 to 16 must be filled by all applicants whether Gazetted or Non Gozetted
1 Name of Applicant :
2 Date of birth :
3 Post held :
4 Department, Office, section :
5 Pay and scale of pay :
6 Date of entry in service :
7 Date of commencement of continuous service:
8 Whether applicant has got confirmation if any post if so from which date and which post :
9 Address during leave :
10 HRA, Conveyance Allowance or other compensatory allowance drawn in the present post :
11 Nature and period of leave applied for and date from which required :
12 Sundays and holidays, if any proposed to be prefixed/suffixed to leave :
13 Ground on which leave is applied for :
14 Date of return from last leave and the nature and period of that leave :
15 a) I undertake to refund the difference between the leave salary drawn during commuted leave and that admissible during half pay leave which would not have been admissible in the event of my retirement from service at the end of during the occurrence of leave.
b) I undertake to refund the leave salary drawn during leave not due which would not have been admission had rule 86, part 1 not been applied in the event of my voluntary retirement or resignation from service at any time until I earn half pay leave not less than the amount or leave not due availed of by me.
16 Place:……………..
Date:………………
Signature of Applicant with date
17 Remarks or Recommendation of the controlling officer
Signature with date
(Designation)
CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE
(By Accountant General (A&E) in the case of Gozetted Officer)
18 Certified that ………………….. ……………………. ………………….. …………… .(Nature of leave) for ………………. from …………… admissible under the rule …………………..of KSR
Signature (with date) Designation
19 Order of the sanctioning authority
Signature (with date) Designation
