Terna Medical College & Hospital Nerul, Navi-Mumbai-400 706

LEAVE APPLICATION FOR INTERN

1. Name of Intern_______________________________________________

2. JUNE/DEC. term with year______________________________________

3. Period of the present term : from__/__/_____to__/__/______

4. Name of the Institution and Placement___________________________

___________________________________________________________

5. Period of leave : from__/__/_____to__/__/______

6. Total number of days of leave___________________________________

7. Previous leave enjoyed________________________________________

8. Remark of the Head of the Unit if any ____________________________

___________________________________________________________

(Signature of the Head of the Unit) Prof. of PSM