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DEPARTMENT OF ELECTRONICS ENGINEERING

INDIAN INSTITUTE OF TECHNOLOGY (INDIAN SCHOOL OF MINES) DHANBAD


JHARKHAND, INDIA, PIN- 826004

REQUEST FOR OUTSTATION LEAVE

No: Dated:

Hostel: ______________________________________________ Room Number: __________________________

Name of Applicant: ___________________________________________________________________________

Admission No: _________________________ Semester ___________________ Branch_____________________

Purpose: ____________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Date and time of leaving station: _________________________________________________________________

Date and time of expected return: ________________________________________________________________

Total days of absent: ___________________________________________________________________________

Contact Telephone Number: _____________________________________________________________________

Signature of Applicant with date

………………………………………………………………………………………………………………………………………………………………………………….

Signature of Head of the Department/ Course Coordinator:

Signature of Warden

Approved/ Rejected

Dean (Acad)/ Associate Dean (Acad)

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