Kimlik Bilgileri

1. Adı Soyadı                    :
2. Hizmet Sınıfı                :
3. Görevi ve Yeri              :
4. Kurum Sicil No            :

İstenen İznin Türü ve Nedeni

1. Mazeret İzni                  :              ………………………………………………………

• Yıl içinde kullandığı süre        ……….     gün

2. Yıllık İzin                       :             (    )  gün

• Bu yıl içinde kullanabileceği toplam süre   (      )      gün
• Ait olduğu yıl / yıllar                                 (  20…./20…. )

3. Aylıksız İzin                    :              ……………………………………………………..

4. Hastalık İzni                    :              …………………………………………………….

5.Diğer İzinler                     :               …………………………………………………….

6. Yol Süresi                        :               …………………………………………………….

Ayrılma ve Başlama Tarihi

1. İzne ayrıldığı tarih                            :…./…./20…
2. Göreve başlama tarihi                      :…./…./20…
 

4. İznini geçireceği adres ve telefon     :…………………………………………….........
………………………………………………………………………………………………
(………..) …………………….. 
                                                                                         ……………/……………                                                               

                                       Yukarıda belirtilen nedene bağlı olarak   (   )   gün izinli sayılmam hususunda
olurlarınızı arz ederim.
                                                                                                                                              …../…../20….
                                                                                                                                                      İMZA
                                                                                                                                                 AD SOYAD
                                                                                                                                           ……………………

Onaylayan Amir

…/…/08       Okul Md       :……………………….                              Ethem SARI                                                                                                                           
                                                                                                                Kaymakam a.
…/…/08        Şb.Md.          :S. AKTAŞ…………...                   İlçe Milli Eğitim Müdürü

                                                                                                                    .../…./20….                                                                                                               
                                                                                                                                        İMZA/MÜHÜR