A  N  N  E  X  U  R  E

FORM OF APPLICATION UNDER LEAVE TRAVEL CONCESSION SCHEME

(FOR ORISSA STATE GOVERNMENT EMPLOYEE ONLY)

- - - -

PART(A)

1.(a) Name, Designation and office of the applicant:

   (b) Date of Birth                                          : 

  (c ) Date of first entry into Government Service:                                         :

2. Date of application                                  :

3. Present scale of Pay                                 :

4. Intended place of visit                             :

5. Date of commencement of the

        Outward journey(proposed)              :

6. Kind of leave to be taken for the

    Purpose and its duration                         :

7. No. of accompanying family members: -

               (i) Name of the first family member:

               (a) Relationship of the Applicant.    :

               (b) Age / date of birth                   :

               (c) Whether married or

                 Unmarried                                    :

               (d) Whether a State Govt. Servant

                (details thereof)                            :

               (e) Monthly income from all sources,

               if any                                            :

  (ii) Name of the second family member:

(a)          Relationship with the applicant:

(b)          Age / date of birth                         :

(c)          Whether married or unmarried :

(d)          Whether a State Govt. Servant :

(details thereof)

 (iii) Name of the Third family member:-

(a)          Relationship with the applicant:

(b)          Age / Date of birth                         :

(c)          Whether married or unmarried:

(d)          Whether a State Govt. Servant :

(details thereof)

(iv) Name of the fourth family member :-

(a)           Relationship with the applicant :

(b)          Age / date of birth                         :

(c)          Whether married or unmarried  :

(d)          Whether a State Govt. Servant  :

(details thereof)

8. Details of place of visit:

               (a) Place of the visit                                      :

               (Please indicate the

               State / Union Territory

               / District / Police Station/

               Town / Muffusil)

               (b)  Mode of Journey                                   :

               (Rail / Road / other mode of

               travel admissible)

               ( c)  Appropriate distance both ways by     :

               shortest direct route                                    

9. Total reimbursable estimated

               cost of journey, both ways                          :

(a)          Appropriate fare by train              :

(b)          Appropriate fare by road              :

(c)          Appropriate fare by

other means of travel                    :

10. Amount of advance applied for           :

               (the application should

               be made at least before

               45 days of the proposed

               date of outward journey)

11. Any other relevant information

               required by the Sanctioning

               Authority                                         :

                                            Full signature of the applicant with date

PART (B)

D  E C  L  A  R  A  T  I  O  N

(a)          That I am aware of the provisions of L.T.C. Rules of the State Government.

(b)          That while on journey and stay during L.T.C. I shall not claim compensation for loss of property / accident unless otherwise admissible

(c)          That, with or family members , I will abide byrestrictions / orders / requisitions as and when necessary during L.T.C. period.

(d)          That my husband / wife being a State Government employees as detailed at para –above , I undertake that he/she has not availed L.T.C. either for self or for family members neither to and he /she will not be entitled for the benefit hereafter. 

12. I may be allowed / Sanctioned L.T.C. benefits as applied for according to rules in vogue

Date:                                                                                Full signature of the applicant with date

Place:

PART (D )

(Receipt to be given to the applicant)

                Received the application of Sri / Smt...................................................designation......................of the office............................................today the......................................202....for grant of L.T.C.

                                                                 Full Signature of the Receiving Officer /

                                                                        date / place / Official seal