CSC Form No.

6
Revised 1995

APPLICATION FOR LEAVE

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

DEPARTMENT OF EDUCATION
2. DATE OF FILLING 4. POSITION 5. SALARY (Monthly)

DETAILS OF APPLICATION
5 A. TYPE OF LEAVE B. WHERE LEAVE WILL BE SPENT

Vacation 1. IN CASE OF VACATION LEAVE

To seek employment Within the Philippines

Others (Specify) Abroad (Specify)

_____________________

Sick 2. IN CASE OF SICK LEAVE

Maternity In Hospital (Specify)

Others (Specify) Out Patient (Specify)

_______________________

C. NUMBER OF WORKING DAYS APPLIED FOR D. COMMUTATION

Requested Not Requested
INCLUSIVE DATES :

ERLINDA M. DELA PEÑA, Ed.D.

Education Program Supervisor I - ALS
Signature of Applicant
Employee Num.:

DETAILS OF ACTION ON APPLICATION

7 A. CERTIFICATION OF LEAVE CREDITS 7 B. RECOMMENDATION
As of __________________________ Approval
Disapproval due to
Vacation Sick Days

Days Days Days

GERMAN E. FLORA
CHIEF EDUCATION SUPERVISOR-CID
Administrative Officer / Personnel Officer Authorized Official

7 C. APPROVED FOR: 7 D. DISAPPROVED

days with pay
days witout pay
days others (Specify)

Approving Official