APPLICATION FOR LEAVE

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

3. Date of Filling 4. POSITION SALARY (Monthly)

DETAILS OF APPLICATION

6. a) TYPE OF LEAVE c) WHERE LEAVE WILL BE

SPENT:
Vacation 1) IN CASE OF VACATION
To seek employment Within the Philippines
Others (specify) Abroad (specify)

2) IN CASE OF SICK LEAVE

X Sick In Hospital (specify)

Maternity
Others (specify) Out Patient (specify)

b) NUMBER OF WORKING DAYS APPLIED FOR: d) COMPUTATION

Requested Not Requested
INCLUSIVE DATES:

Signature of Applicant

DETAILS OF ACTION ON APPLICATION

7. A) CERTIFICATION OF LEAVE CREDITS 7.B) RECOMMENDATION

As of Approved
Disapproved due to

Vacation Sick Total

___________________
Section
(Authorized Official) (Authorized Official)

c) APPROVED FOR: d) DISAPPROVED DUE TO:

Days with pay
Days without pay
Others (specify)

_________________
(Authorized Official)