MC Form

Est-95
Signature of applicant……………………
(A Govt:of India Enterprise)

Medical Certificate for Non- gazetted officer recommended for leave, extension of
COMMUTATION LEAVE
(Govt:of India/Finance Dept; No173. S.R. dated 16th March 1931)
I…………………………………………………….after careful examination of the case hereby

certify that Sri…………………………………………………..........Whose Signature is given
above is suffering from…………………………………………And is considered that a period of
absence from duty of………………………..with effect from……………………………………
is absolutely necessary for the restoration of his/her health.
Date………………….. Govt: Medical attendant/Reg:

Practioner (No-……………….)
……………………………………………………………………………………………
(A Govt:of India Enterprise )

MEDICAL CERTIFICATE OF FITNESS TO RETURN TO DUTY
Signature of Applicant…………………………….
I………………………………………………Civil Surgeon/Registered Medical practitioner

do hereby certify That I have carefully examined ……………………………………………
of the Department……………………….. Whose Signature is given above with and find that
he/she has recovered from the illness and is now fit it resume his/her duties in Govt: Service. I
also certify that before arriving at his decision I have examined the original Medical certificate
and statements of the case (or certified copies there of) on which leave was granted or extended
and have that taken these into consideration in arriving at my decision.
Date……………………. Govt: Medical attendant or Reg:
Practitioner (No-……………….)
Place…………………….
LEAVE S.R.-1
APPLICATION
(A Govt: of India Enterprise )

FORM OF APPLICATION FOR LEAVE
See suplimentary rule-218 second Schedule (See rule 3 each )
Form-1 ( See Rule 14 )
NOTE: Item 1to 11 must be filled in by all applicants whether gazetted or Non-gazetted.
1. Name of the applicant...........................................................................................................................
2. Leave rule applicable............................................................................................................................
3. Post held ..............................................................................................................................
4. Department office and section..............................................................................................................

5. Pay .................................................................................................................................
6. House rent Allowance, or other Compensatory

Allowance drawn in the present post ....................................................................................................
7. Nature and period of leave applied for and
Date from which required ......................................................................................................................
8. Sundays and holidays, if any ,proposed to be pre-fix
or suffixed to leave, .................................................................................................................................
9. Ground on which leave is applied for. ...................................................................................................
10. Date of return from last leave and the nature
and period of that leave,...........................................................................................................................
11. I propose / donot propose toavail mysef of
leave travel concession for the block
years ...........................during the ensuring leave.................................................................
date.............................................. Signature of applicant.....................................
Place.............................................
12. Remarking and / or recomedation

Of the controlling officer
Date....................................... Signature.........................................................
Place.................................... Designation...................................................
CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE
13. I ....................................................................................................................certified that

( Nature of leave )or from ..........................To..............................is admissible under
rule ................................................................of the CCS ( leave )rules1972.
Date ....................................... Signature .......................................

Designation ...................................
14. Orders of the sanctioning authority :
Date ........................... Signature......................................

Designation.....................................
*If the applicant is drawing any compensatory allowance, the sanctioning authority should state whether on the expiry of leave he is likely to
the same post to another post carring a similar allowance.

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Est-95

(A Govt:of India Enterprise)

I…………………………………………………….after careful examination of the case hereby

Date………………….. Govt: Medical attendant/Reg:

(A Govt:of India Enterprise )

I………………………………………………Civil Surgeon/Registered Medical practitioner

Date……………………. Govt: Medical attendant or Reg:

(A Govt: of India Enterprise )

4. Department office and section..............................................................................................................

6. House rent Allowance, or other Compensatory

12. Remarking and / or recomedation

13. I ....................................................................................................................certified that

Date ....................................... Signature .......................................

14. Orders of the sanctioning authority :

Date ........................... Signature......................................

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