(CSC FORM No. 6 Revised 1985) (CSC FORM No.

6 Revised 1985)

APPLICATION FOR LEAVE APPLICATION FOR LEAVE

TYPE OF LEAVE (Please check appropriate box) TYPE OF LEAVE (Please check appropriate box)
Name: _____________________________________ Name: _____________________________________

Signature: __________________________________ Vacation Leave Signature: __________________________________ Vacation Leave

Position: __________________________________
Monthly Salary: ______________________________
Office/School: _______________________________
Date Filing: _________________________________
No. of Working Days Applied for: _________________
Inclusive Date/s: _____________________________
Commutation:
Requested: _______ Not Requested: _______
Within the Philippines Position: __________________________________ Within the Philippines
Abroad (Please specify) _____________ Monthly Salary: ______________________________ Abroad (Please specify) _____________
Sick Leave Office/School: _______________________________ Sick Leave
Out Patient Date Filing: _________________________________ Out Patient
In Hospital (Please specify) __________ No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
( ) Maternity Leave ( ) Rehabilitation Leave Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
( ) Paternity Leave ( ) Study Leave Commutation: ( ) Paternity Leave ( ) Study Leave
( ) Forced Leave ( ) Special Emergency Leave Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges ( ) Special Leave Privileges

FOR PERSONNEL USE ONLY ( ) Monetization of ( ) Solo Parent/Parental FOR PERSONNEL USE ONLY ( ) Monetization of ( ) Solo Parent/Parental
Leave Credits Leave Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710 Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs) as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION: ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________ Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

VILMA A MAGBIRAY VILMA A. MAGBIRAY

_______________________________ ______________________________
CERTIFIED BY: School Head CERTIFIED BY: School Head

( ) APPROVED FOR: ______ days with pay ( ) APPROVED FOR: ______ days with pay
ROCHELLE G. OPIANA ______ days without pay ROCHELLE G. OPIANA ______ days without pay
HRMO ( ) DISAPPROVED due to: _________________ HRMO ( ) DISAPPROVED due to: _________________
Administrative Officer IV Administrative Officer IV

ROMMEL R. JANDAYAN, Ed.D, CESE ROMMEL R. JANDAYAN, Ed.D, CESE

 OIC-ASDS OIC-ASDS
LF-1-04 LF-1-04

(CSC FORM No. 6 Revised 1985) (CSC FORM No. 6 Revised 1985)

APPLICATION FOR LEAVE APPLICATION FOR LEAVE

Name: _____________________________________ TYPE OF LEAVE (Please check appropriate box) Name: _____________________________________ TYPE OF LEAVE (Please check appropriate box)

Signature: __________________________________ Vacation Leave Signature: __________________________________ Vacation Leave

Position: __________________________________ Within the Philippines Position: __________________________________ Within the Philippines
Monthly Salary: ______________________________ Abroad (Please specify) _____________ Monthly Salary: ______________________________ Abroad (Please specify) _____________
Office/School: _______________________________ Sick Leave Office/School: _______________________________ Sick Leave
Date Filing: _________________________________ Out Patient Date Filing: _________________________________ Out Patient
No. of Working Days Applied for: _________________ In Hospital (Please specify) __________ No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
Commutation: ( ) Paternity Leave ( ) Study Leave Commutation: ( ) Paternity Leave ( ) Study Leave
Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges ( ) Special Leave Privileges
( ) Monetization of ( ) Solo Parent/Parental ( ) Monetization of ( ) Solo Parent/Parental
FOR PERSONNEL USE ONLY FOR PERSONNEL USE ONLY
Leave Credits Leave Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710 Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs) as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION: ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________ Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

VILMA A MAGBIRAY
_______________________________ VILMA A. MAGBIRAY
______________________________
CERTIFIED BY: School Head CERTIFIED BY: School Head
 ( ) APPROVED FOR: ______ days with pay ( ) APPROVED FOR: ______ days with pay
ROCHELLE G. OPIANA ______ days without pay ROCHELLE G. OPIANA ______ days without pay
HRMO ( ) DISAPPROVED due to: _________________ HRMO ( ) DISAPPROVED due to: _________________
Administrative Officer IV Administrative Officer IV

ROMMEL R. JANDAYAN, Ed.D, CESE ROMMEL R. JANDAYAN, Ed.D, CESE

OIC-ASDS OIC-ASDS
LF-1-04 LF-1-04
(Please check appropriate box)
(Please check appropriate box)
(CSC FORM No. 6 Revised 1985)

APPLICATION FOR LEAVE

TYPE OF LEAVE (Please check appropriate box)
Name: _____________________________________

Signature: __________________________________ Vacation Leave

Position: __________________________________ Within the Philippines
Monthly Salary: ______________________________ Abroad (Please specify) _____________
Office/School: _______________________________ Sick Leave
Date Filing: _________________________________ Out Patient
No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
Commutation: ( ) Paternity Leave ( ) Study Leave
Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges
( ) Monetization of ( ) Solo Parent/Parental
FOR PERSONNEL USE ONLY FOR PERSON
Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

_________________________
CERTIFIED BY: (Immediate Supervisor)

( ) APPROVED FOR: ______ days with pay

ROCHELLE G. OPIANA ______ days without pay
HRMO ( ) DISAPPROVED due to: _________________
Administrative Officer IV

DR. JOSEPHINE L. FADUL

Schools Division Superintendent
LF-1-04
(CSC FORM No. 6 Revised 1985)

APPLICATION FOR LEAVE

TYPE OF LEAVE (Please check appropriate box)
Name: _____________________________________

Signature: __________________________________ Vacation Leave

Position: __________________________________ Within the Philippines
Monthly Salary: ______________________________ Abroad (Please specify) _____________
Office/School: _______________________________ Sick Leave
Date Filing: _________________________________ Out Patient
No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
Commutation: ( ) Paternity Leave ( ) Study Leave
Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges
( ) Monetization of ( ) Solo Parent/Parental
FOR PERSONNEL USE ONLY
Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

_________________________
CERTIFIED BY: (Immediate Supervisor)

( ) APPROVED FOR: ______ days with pay

ROCHELLE G. OPIANA ______ days without pay
HRMO ( ) DISAPPROVED due to: _________________
Administrative Officer IV

DR. JOSEPHINE L. FADUL

Asst. Schools Division Superintendent
LF-1-04
(CSC FORM No. 6 Revised 1985)

APPLICATION FOR LEAVE

TYPE OF LEAVE (Please check appropriate box)
Name: _____________________________________

Signature: __________________________________ Vacation Leave

Position: __________________________________ Within the Philippines
Monthly Salary: ______________________________ Abroad (Please specify) _____________
Office/School: _______________________________ Sick Leave
Date Filing: _________________________________ Out Patient
No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
Commutation: ( ) Paternity Leave ( ) Study Leave
Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges
( ) Monetization of ( ) Solo Parent/Parental
FOR PERSONNEL USE ONLY FOR PERSON
Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

COMPUTATION: DR. EDUARD C. AMOGUIS

CID - CHIEF
P __________ X ____ X .0481927= P ____________
( ) APPROVED FOR: ______ days with pay
CERTIFIED BY: ______ days without pay
( ) DISAPPROVED due to: _________________

ROCHELLE G. OPIANA
HRMO DR. JOSEPHINE L. FADUL
Administrative Officer IV Asst. Schools Division Superintendent
LF-1-04
(CSC FORM No. 6 Revised 1985)

APPLICATION FOR LEAVE

TYPE OF LEAVE (Please check appropriate box)
Name: _____________________________________

Signature: __________________________________ Vacation Leave

Position: __________________________________ Within the Philippines
Monthly Salary: ______________________________ Abroad (Please specify) _____________
Office/School: _______________________________ Sick Leave
Date Filing: _________________________________ Out Patient
No. of Working Days Applied for: _________________ In Hospital (Please specify) __________
Inclusive Date/s: _____________________________ ( ) Maternity Leave ( ) Rehabilitation Leave
Commutation: ( ) Paternity Leave ( ) Study Leave
Requested: _______ Not Requested: _______ ( ) Forced Leave ( ) Special Emergency Leave
( ) Special Leave Privileges
( ) Monetization of ( ) Solo Parent/Parental
FOR PERSONNEL USE ONLY
Leave Credits Leave
VL SL TOTAL ( ) Terminal Leave ( ) Leave Privilege under
Leave Balance R.A. 9262/9710
as of: __________ _______ _______ ________ ( ) Others: ( ) CTO (Used COCs)
Less: This Leave _______ _______ ________ ( ) n
ACTION ON APPLICATION:
Balance _______ ________ ________ ( ) Approval ( ) Disapproval due to: _________

COMPUTATION: DR. EDUARD C. AMOGUIS

CID - CHIEF
P __________ X ____ X .0481927= P ____________
( ) APPROVED FOR: ______ days with pay
CERTIFIED BY: ______ days without pay
( ) DISAPPROVED due to: _________________

ROCHELLE G. OPIANA
HRMO DR. JOSEPHINE L. FADUL
Administrative Officer IV Asst. Schools Division Superintendent
LF-1-04