C.S.C.

Form 6
APPLICATION FOR LEAVE
1. OFFICE/AGENCY 2. NAME (LAST) (FIRST) (MIDDLE)

DepEd Regional Office No. X

3. DATE OF FILING 4. POSITION 5. SALARY

Details of Application
6.a) TYPE OF LEAVE 6.b) WHERE LEAVE TO BE SPENT
(1) IN CASE OF VACATION LEAVE
VACATION LEAVE _______________ Within the Phils.
Abroad (Specify)
__________ To seek employment
__________ Others (Specify)
(2) IN CASE OF SICK LEAVE
_______________ In Hospital (Specify)
SICK LEAVE
MATERNITY LEAVE
OTHERS (Specify)

6.c) NUMBER OF DAYS APPLIED 6.d) COMMUTATION

/ Requested ________Not Requested
INCLUSIVE DATES

______________________________
Signature of Applicants
Details of Action Application
7. a) CERTIFICATION OF LEAVE CREDITS 7. b) RECOMMENDATION
As of ____________________________ APPROVAL
DISAPPROVAL due to
VACATION SICK TOTAL

DAYS DAYS DAYS

ELIEL E. APORBO
JOHNNY M. BELOY School Head
Administrative Officer V (Authorized Official)
7.c) APPROVED FOR 7.d) DISAPPROVED DUE TO:
___________DAYS WITH PAY ____________________________________
___________DAYS WITHOUT PAY ____________________________________
___________OTHERS (Specify)
___________________

AGUSTINES E. CEPE, Ph.D.,CESO VI

Schools Division Superintendent
(Authorized Official)
Date: ____________________

1. 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.
2. Application for Vacation Leave shall be filed in advance or whenever possible five (5) days before going such leave.
3. Application for Sick Leave filed in advance or exceeding five (5) days shall be accomplished by a Medical Certificate.
In case medical consultation was not availed of, an affidavit should be executed by the physician.
4. An employee who is absent without approved leave shall not be entititled to receive his salary corresponding to the
period his unauthorized leave of absence.
5. An application of leave of absence for (30) days or more shall be accompanied by a clearance form from any
property accountabilities.