CS Form No.

APPLICATION FOR LEAVE

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

DEPARTMENT OF EDUCATION
3. DATE OF FILING 4. POSITION 5. First Day of Service & Employee No. 6. SALARY (Monthly)

DETAILS OF APPLICATION

7(A) TYPE OF LEAVE 7(B) WHERE LEAVE WILL BE SPENT

Vacation (1) In case of Vacation Leave
To seek employment Within the Philippines
✘ Others (Specify) Abroad (please specify)

Sick (2) In case of Sick Leave

Maternity In hospital (please specify)
Others (Specify)
Out-patient (please specify)

7(c) Number of working days applied for (3) Commutation

working days ✘ Requested
Not Requested
Inclusive Date/s:

(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

8(A) CERTIFICATE OF LEAVE CREDITS 8(B) RECOMMENDATION
As of ✘ APPROVAL
DISAPPROVED due to:
Vacation Sick Total
(Days) (Days) (Days)

JOCELYN D. LOYOLA LIFEJEANA JESUSA H. LONGAKIT

Administrative Officer V (Authorized Official/Immediate Head)

8(C) APPROVED FOR: 8(D) DISAPPROVED DUE TO:

days with pay

days without pay
others (please specify)

for:

ORLANDO G. CADANO EdD

Assistant Schools Division Superintendent
Officer-In-Charge
Office of the Schools Division Superintendent

by:
MICHAELANGELO R. SAURO PhD
Assistant Schools Division Superintendent