APPLICATION FOR LEAVE

CSC FORM NO. 6

Revised 1984

1. OFFICE/ AGENCY: 2. NAME: (Last) (First) (Middle)

3. DATE OF FILING: 4. POSITION: 5. SALARY (Monthly)

6. TYPE OF LEAVE 6. (a) WHERE LEAVE WILL BE SPENT

1. IN CASE OF VACATION LEAVE
VACATION
Within the Philippines
MANDATORY LEAVE
Outside the Philippines
SPECIAL LEAVE PRIVILEGES ___________________
X 2. IN CASE OF SICK LEAVE
SICK LEAVE
In HOSPITAL (Specify) _______________
X MATERNITY
X Out patients (Specify)
Others (Specify)
6.(b) NUMBERxOF WORKING DAYS APPLIED FOR 6.(c) COMMUTATION
X
Requested Not Requested
INCLUSIVE DATES ________________________

AUTHORIZED BY:
___________________________ Applicant

DETAILS OF ACTION ON APPLICATION

7.(a) CERTIFICATION OF LEAVE CREDITS 7.(b) RECOMMENDATION
As of__________________________
Approval

COMPUTATION Disapproved due to ___________________

____________________________________
V/L S/L TOTAL
Balance as of _______________________________________________
Plus accum. Leaves
From _____________to ________________________________________
Total accum. Leaves ___________________________________________

Less: this leave

From ______________________________________________________
Balance as of ___________ __________________________________

___________________________
Human Resource Mgt. Officer

7.(c) APPROVED FOR: 7.(d) DISAPPROVED DUE TO:

__________day with pay _________________________
________ _days without pay _________________________
_________ Others (Specify)

ANTONIO H. CERILLES
Provincial Governor