CS Form No.

6
Revised 1984

Department of Education
Region VI – Western Visayas
SCHOOLS DIVISION OF ILOILO
La Paz, Iloilo City

________________________________________________________________________________________________
APPLICATION FOR LEAVE
1. OFFICE/AGENCY 2. NAME (Last) (First) (Middle)
Schools Division of Iloilo
3. DATE OF FILING 4. POSITION 5. SALARY(Monthly)
DECEMBER 16, 2019 NURSE II 30, 531.00
DETAILS OF APPLICATION
6. A) TYPE OF LEAVE: 6. B) WHERE LEAVE WILL BE SPENT:
(1) IN CASE OF VACATION LEAVE
Vacation Within the Philippines
To seek employment Abroad (Specify)
Others (specify) (2) IN CASE OF SICK LEAVE
In hospital (Specify)
Sick
Maternity / Paternity Out Patient
Others (Specify)
_____________________________

6. C) NUMBER OF WORKING DAYS APPLIED FOR. 6. D) COMMUNICATION

APPLIED FOR_____1 DAY__________ __ Request
INCLUSIVE DATES DECEMBER 16, 2019____ __ Not Requested

_______________________________
Signature of Applicant
Employee No. __6385258___________
Date of Original Appointment __FEB. 26, 2018___

DETAILS OF ACTION ON APPLICATION

CERTIFICATION OF LEAVE CREDITS RECOMMENDATION
7. a) CERTIFICATION OF LEAVE CREDITS 7. b) RECOMMENDATION
As of Approval

Vacation Sick CTO/COC PL Others TOTAL Disapproval

EARNED ___________________________
SPENT ___________________________
BALANCE

_________________________________ _________________________
MIKEE GRACE N. MONTECLARO GILBERT D. SOLIDUM
Administrative Officer IV Chief, SGOD

7. c) APPROVED FOR: 7. d) DISAPPROVED DUE TO:

_____________days with pay _____________________________
_____________days without pay _____________________________
_____________others (Specify)

______________________________________
AZUCENA T. FALALES, Ph.D.
Assistant Schools Division Superintendent
Date: ______________________