REPUBLIC OF THE PHILIPPINES

PHILIPPINE STATISTICS AUTHORITY

APPLICATION FOR LEAVE

APPLICANT'S PROFILE
1. NAME: (LAST) (FIRST) (MIDDLE)

2. Position/Designation: 3. Monthly Salary:

4. Unit/Section/Division/Office:
DETAILS OF APPLICATION
5. Date of Filing:
6.A. TYPE OF APPLICATION 6.C. WHERE LEAVE WILL BE SPENT:
[ ]VACATION 1 IN CASE OF VACATION LEAVE
( ) Forced Leave ( ) Within the Philippines
( ) To seek for employment ( ) Abroad, (specify):
( ) Other, (specify) : ______________
2 IN CASE OF SICK LEAVE
[ ] Sick Leave ( ) In Hospital
(specify):
[ ] Maternity
( ) Out Patient
[ ] Others, (specify): Filial (specify):

6.B. NUMBER OF WORKING DAYS FOR: 6.D. COMMUTATION

Inclusive Dates: _________________________ ( ) Requested ( x ) Not Requested

____________________________________________
Signature over printed name of the applicant
DETAILS OF ACTION TO THE APPLICATION
7.A. CERTIFICATION OF LEAVE CREDITS: 7.B. RECOMMENDATION
As of ( ) Approved
( ) Disapproved
Vacation Sick Total (specify): ________________________
________________________________

CHRISTINE JOANN L. GONZAGA DULCE M. DIONISIO

Administrative Officer I Supervising Statistical Specialist

7.C. APPROVED BY:

days with pay _____days without pay

others (specify)

APPROVED/DISAPPROVED:

NORMAN L. BUNDALIAN
Chief Statistical Specialist