CSC FORM NO.

6 REVISED 1984
1. OFFICE/ AGENCY

2. NAME

(Last)

(First)

MONTON

DEPED-HINUNDAYAN

(Middle)

ROEL

ALIBANGBANG

3. DATE

4. POSITION

5. SALARY (Monthly)

TEACHER 3

Php 22, 328.00

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

6.(a) TYPE OF LEAVE

______ Vacation/ FORCED LEAVE

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

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 _____________
_________________________________________
_________________________________________

BIMBO P. TOUZO-P1
Authorized Official

Administrative Officer / HRMO

7. (c) APPROVED
__________
__________
__________

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

7. (d) DISAPPROVED DUE TO:

______________________
______________________
______________________

_______________________
Administrative Officer Designate
Date: ____________

INSTRUCTIONS
1.
2.
3.
4.

Application for vacation or sick leave for one full day or more shall be made on this form and to be accomplished at
least in duplicate.
Application for vacation leave shall be filed in advance or whenever possible five (5) days before going on such leave.
Application for a sick leave filed in advance, or exceeding five (5) days shall be approximately by medical certificate. In
case medical consultation was not availed of, an affidavit should be executed by the applicant.
An applicant for leave of absence for thirty (30) working days or more shall be accompanied by clearance from money
and property accountabilities.