CSC Form 6

Revised 1984 School & District:______________

1. Office Agency NAME (LAST) (FIRST) (MIDDLE)

DepEd-Division of San Pablo City

3.DATE OF FILING POSITION EMPLOYEE NO. MONTHLY SALARY

6. a) TYPE OF LEAVE b.) WHERE LEAVE WILL BE SPENT

_______________________________Vacation
_______________________________ To seek employment
_______________________________ Others(Specify) _________
______________________________________________________
_______________________________ Sick
_______________________________ Maternity
_______________________________ Others )Specify)
______________________________________________________
1. IN CASE OF VACATION LEAVE
____________________ within the Philippines
____________________ Abroad (Specify)
___________________________________________
2. IN CASE OF SICK LEAVE
_________________ In Hospital (Specify)________
___________________________________________
_______OUT PATIENT (Specify) ______________

c. NUMBER OF WORKING DAYS APPLIED FOR d) _________Requested __________Not Requested

_______________________________________________________
INCLUSIVE DATES_____________________________________
______________________________________________________

_________________________________________
(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION ‘

a)CERTIFICATION OF LEAVE CREDITS b)RECOMMENDATIONS
as of ________________________________________ _______________________Approved
_______________________Disapproved due to
____
Vacation Sick Total

__________________________
(Immediate Supervisor)

LUCILA NIDA B. RODELAS

Administrative Officer IV

APPROVED FOR:

____________________ days with pay

____________________ days without pay
____________________ others (Specify)

APPROVED:

_________________________________________
DAISY Z. MIRANDA, CESO VI
Assistant Schools Division Superintendent
Officer-In-Charge Schools Division Superintendent

____________________________
Date

Instruction: (1) Application for vacation or sick leave for one full day or more shall be made on this form and to be accomplished at
least in duplicate (2) Application for vacation shall be filled in advance or whenever possible five (5) days before going on such
leave. (3) Application for sick leave filed in advance or exceeding five days shall be accomplished by a medical certificate. In case
medical consultation was not availed of an affidavit should be executed by the patient. (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 for leave of absence for 30 days or more shall be accompanied by a clearance from money and property accountability.

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