APPLICATION FOR LEAVE

1.OFFICE/AGENCY: _________________2. NAME( LAST)____________________(FIRST)_______________________________MIDDLE:______

3. DATE OF FILING:__________________ 4..POSITION:_______________________________5. SALARY(Monthly) Php_____________________

DETAILS OF APPLICATION
_________________________________________________________________________________________________________________________________________________________________________________________________________________

6. (A.)TYPE OF LEAVE

6. (B)WHERE LEAVE WILL BE SPENT

Vacation
To seek employment
Others ( Specify) ___________
Death____________ Place ________________
Injury____________Place_________________
Sickness (Pls. Specify):____________________
Maternity:_____________________________
Others: (Specify)________________________
6 (C.) NUMBER OF WORKING DAYS APPLIED FOR:
____________________________________
INCLUSIVE DATE: ______________________

1. In case of vacation
Within the Philippines
Abroad( Specify)_____________

In 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

As of ______________________
Vacation
Days

Sick
Days

B.) RECOMMENDATION

Total
Days

Approval
Disapproved due to: ________________________
_______________________________________

SUSAN MARIE P. BARTOLOME, Ph.D.

Administrative Officer V

______________________________________
(Authorized Official)

C.) APPROVED FOR:

__________days with pay
__________days without pay
__________others ( specify)

D.) APPROVED DUE TO:

_________________________________
_________________________________
________________________________

LILY LL. DOMINGO, Ed.D.,CESO VI

Asst. Schools Division Superintendent
Officer In-Charge
Office of the Schools Division Superintendent

FEBRUARY 2013

MARCH 2013