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Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT


Cordillera Administrative Region
BENGUET PROVINCIAL OFFICE
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
NOTE:
A. Francisco Gold Condominium II, EDSA corner Mapagmahal St., Diliman, Quezon City
Telephone Number 925.11.48 • 925.88.88 • 925.03.32
www.dilg.gov.ph
Republic of the Philippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
Cordillera Administrative Region
BENGUET PROVINCIAL OFFICE
DEPARTMENT OF THE INTERIOR FOR
APPLICATION ANDLEAVE
LOCAL GOVERNMENT CSC Form No. (Revised 1985)
A. Francisco Gold Condominium II, EDSA corner Mapagmahal St., Diliman, Quezon City
Telephone Number 925.11.48 • 925.88.88 • 925.03.32
www.dilg.gov.ph

Name TYPE OF LEAVE

Signature VACATION

Position Within the Philippines Abroad (Specify)

Mo. Salary

Office/Division SICss Sick Leave

Date of Filing /// Out Patient (specify) In Hospital (specify)

No. of working days applied for

Inclusive Dates FORCED LEAVE CSC-SPL

COMMUTATION: MATERNITY REHABILITATION

Requested Not Requested TERMINAL Others (specify)

FOR PERSONNEL USE ONLY: ACTION ON APPLICATION


Recommending:
VL SL TOTAL
Leave credits as of Approval

Disapproval due to
Less: This Leave

Balance:

[Authorized Official]
CERTIFIED BY:-

APPROVED FOR
Chief, Personnel Section
Days w/ Pay

Days w/o Pay


Carded by:
DISAPPROVED DUE TO
Date:

[Authorized Official]