Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

Region VII, Sudlon, Lahug, Cebu City
Tel Nos. 255-7730 & 253-5471 ; Fax. No. 253-5473
Email address: info@dilgregion7.net

APPLICATION FOR LEAVE CSC Form No. (Revised 1985)

Name: ROJHELOU J. PATAC TYPE OF LEAVE

VACATION
Signature: ______________________________________
Within the Philippines Abroad (Specify)
Position: LGOO VI __________________________ ________________________

Mo. Salary: ON FILE / SICK

Out Patient (specify) In Hospital (Specify)

Office/Division: ASTURIAS
__________________________ ________________________
Date of Filing: JULY 31, 2018
FORCED LEAVE CSC-SPL
No. of working days applied for: ONE
MATERNITY REHABILITATION

Inclusive Dates: JULY 30, 2018 TERMINAL Others (specify)

COMMUTATION: ACTION ON APPLICATION

Recommending:
/ Requested Not Requested
Approval
FOR PERSONNEL USE ONLY:
Disapproval due to _______________________
VL SL TOTAL _______________________________________
Leave credits as of

_______________ _________ ________ __________

Less This Leave _________ ________ __________ Program Manager / Cluster Head
(Authorized Official)

Balance: _________ _______ _________ APPROVED FOR

CERTIFIED BY: ___________________________ Days w/ Pay
___________________________ Days w/o Pay

DISAPPROVED DUE TO _________________

Admin Officer _______________________________________

Carded by: ________________________________

Date: ___________________________________ JEROME G. GONZALES

Provincial Director
(Authorized Official)