CSC Form No.

6
Revised 1984 APPLICATION FOR LEAVE
1. OFFICE/AGENCY: 2. NAME: (Last) (First) (Middle
DOLE REGIONAL OFFICE NO. 9 ABDUHASAD =YUSEP AMIL
3. DATE OF FILING: 4. POSITION: 5. SALARY (Monthly):
LABOR AND EMPLOYMENT OFFICER III P 36,628

6.a. TYPE OF LEAVE DETAILS OF APPLICATION

6.b. WHERE LEAVE WILL BE SPENT
[ ] Vacation 1. IN CASE OF VACATION LEAVE
[ ] To seek employment [ ] Within the Philippines
[ ] Others (Specify) [ ] Abroad (Specify) _________________________
]
[ ] Sick 2. IN CASE OF SICK LEAVE
[ ] In Hospital (Specify) _________________________
[ ] Maternity
[ ] Out-patient (Specify) _________________________
[ ] Others (Specify)
6.d. COMMUTATION
[ ] Requested [ ] Not Requested
6.c. NUMBER OF WORKING
DAYS APPLIED FOR

INCLUSIVE DATE/S: ___________________________________________

(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

7.a. RECOMMENDATION 7.b. APPROVAL
[ ] Approval [ ] Approval
[ ] Disapproval due to _______________________________ [ ] Disapproval due to _______________________________

MIRAFLOR J. CASANES ATTY. ROY L. BUENAFE

____________ ___________ ____________ _____________
Division Chief Regional Director

TO BE FILLED UP BY HRDS/IMSD
8.a. CERTIFICATION OF LEAVE CREDITS 8.b. ACTION TAKEN
as of ________________ day/s with pay
________________ day/s without pay
VACATION SICK TOTAL
------------------------------------------------------------------------------
Days REMARKS
7.a. CERTIFICATION
Days OF LEAVE CREDITS Days

_GAY IRIS T.S. TANGCALAGAN_ Date: ______________________

HRMO

INSTRUCTIONS
1. Application for vacation or sick leave for one (1) 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 on such leave.
3. Application for sick leave filed in advance, or exceeding five (5) days shall be accompanied by a medical certificate. In case
medical consultation was not availed of, an affidavit shall be executed by the applicant.
4. An employee who is absent without approved leave shall not be entitled to receive his salary corresponding to the period of
his authorized leave of absence.
5. An application of leave of absence for thirty (30) calendar days or more shall be accompanied by a clearance from money or
property responsibilities. Pursuant to DOLE Administrative Order No. 328, series of 2011 on Leave of Absence, applications
for VL or SL for sixteen (16) days and above of Division Chief and below in the Central Office shall be approved by the
Undersecretary for Internal Affairs.