CS Form 6

Revised 1994

1. OFFICE/AGENCY

APPLICATION FOR LEAVE

2. NAME:
(Last)
(First)

(Middle)

Cubian

Danzalan

Conalum Elem. School/Dep.Ed Inopacan

3. DATE OF FILING

6. a) TYPE OF LEAVE
[ ]

4. POSITION

[
[
[

5. SALARY (Monthly)

DETAILS OF APPLICATION
6. b) WHERE LEAVE BE SPENT:

Vacation
[
[

Rubie Ann II

1.) IN CASE OF VACATION LEAVE

] To seek employment
] Others (Specify)
_________________
]Sick
] Maternity
] Others (Specify) _________

6. c) NUMBER OF DAYS APPLIED FOR

_________________________________
INCLUSIVE DATES ______________
_________________________________

[
[

] Within the Philippines

] Abroad (Specify) _______________________
______________________________________
2.) IN CASE OF SICK LEAVE
[ ] Hospital (Specify) ______________________
[ ] Out Patient (Specify) ____________________
6. d) COMMUTATION
[ ] Requested

] Not Requested

____________________________________
(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

7. a) CERTIFICATION OF LEAVE CREDITS
7. b) RECOMMENDATION
AS OF ________________________________
[ ] Approval
[ ] Disapproval due to __________
Vacation:
Sick:
Total:
______days ________ days_______days
_____________________________
HRMO I
7.c. APPROVED FOR:
________ days with pay
________ days without pay
________ others (Specify)

_______________________
Immediate Supervisor

7. d) DISAPPROVED DUE TO:

______________________________
______________________________

____________________________
AUTHORIZED OFFICIAL
Date ___________