1.

OFFICE/ AGENCY

2. NAME
(Middle)

3. DATE

4. POSITION

(First)

5. SALARY (Monthly)

DETAIL OF APPLICATION
6. (b) WHERE LEAVE WILL BE SPENT
(1) IN CASE OF VACATION LEAVE

6.(a) TYPE OF LEAVE

[
[
[

(Last)

] Vacation/ FORCED LEAVE

] To seek employment
] Others (Specify) (Special) Mourning

[
[

] Within the Philippines

] Abroad (specify) ____________________

Leave
[ ] Sick
[ ] Maternity
6. (c) NUMBER OF WORKING DAYS APPLIED FOR:

6. (2) IN CASE OF SICK LEAVE

[
[

] in hospital (specify) ___________________

_____________________________________
] out patient (specify) ___________________
_____________________________________

INCLUSIVE DATES
COMMUTATION

____________________________
____________________________
____________________________
____________________________

] Requested

] Not requested

______________________
(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

7. (a) CERTIFICATION OF LEAVE CREDITS

7. (b) RECOMMENDATION

as of ___________________________
Vacation

Sick

Total

[ ] Approved
[ ] Disapproved due to ___________________
_________________________________________
_________________________________________

_____________________

______________________

Principal 1

Administrative Officer

7. (c) APPROVED
__________
__________
__________

FOR:
Days with pay
Days with out pay
Others (specify)

7. (d) DISAPPROVED DUE TO:

______________________
______________________
______________________
________________
Signature
_______________________
Administrative Officer Designate

Date: ____________