Employee’s Copy Chief Finance Officer/ Hospital Administrator

HA’s Copy

Republic of the Philippines

Department of Health Republic of the Philippines
KARMELLI CLINIC & HOSPITAL CORPORATION Department of Health Republic of the Philippines
HUMAN RESOURCE OFFICE KARMELLI CLINIC & HOSPITAL CORPORATION Department of Health
#2 Legaspi St. Brgy. 29, Sto. Tomas 2do, Laoag City, Ilocos Norte 2900
HUMAN RESOURCE OFFICE KARMELLI CLINIC & HOSPITAL CORPORATION
Tel Nos. ER (077) 772-27-52 or Records/PhilHealth Office (077) 670-70-64
#2 Legaspi St. Brgy. 29, Sto. Tomas 2do, Laoag City, Ilocos Norte 2900 HUMAN RESOURCE OFFICE
APPLICATION FOR LEAVE Tel Nos. ER (077) 772-27-52 or Records/PhilHealth Office (077) 670-70-64 #2 Legaspi St. Brgy. 29, Sto. Tomas 2do, Laoag City, Ilocos Norte 2900
Name: LYNDEN GAYLE V. CLEMENTE APPLICATION FOR LEAVE Tel Nos. ER (077) 772-27-52 or Records/PhilHealth Office (077) 670-70-64

Date of Filing: Position: ACU STAFF NURSE Name: LYNDEN GAYLE V. CLEMENTE APPLICATION FOR LEAVE
DETAILS OF APPLICATION Date of Filing: Position: ACU STAFF NURSE Name: LYNDEN GAYLE V. CLEMENTE
TYPE OF LEAVE: Number of Days Applied for: DETAILS OF APPLICATION Date of Filing: Position: ACU STAFF NURSE
[ ] Vacation Leave Inclusive Date/s: TYPE OF LEAVE: Number of Days Applied for: DETAILS OF APPLICATION
[ ] Sick Leave _________________________ [ ] Vacation Leave Inclusive Date/s: TYPE OF LEAVE: Number of Days Applied for:
( ) With Medical Certificate & Signature [ ] Sick Leave __________________________ [ ] Vacation Leave Inclusive Date/s:
Copies of Test Results Vacation Destination: ( ) With Medical Certificate & Signature [ ] Sick Leave __________________________
[ ] Emergency Leave ( ) Within the Philippines Copies of Test Results Vacation Destination: ( ) With Medical Certificate & Signature
Reason/s:_______________ ( ) Abroad (Specify): [ ] Emergency Leave ( ) Within the Philippines Copies of Test Results Vacation Destination:
( ) Excused, with Letter & ____________________ Reason/s:_______________ ( ) Abroad (Specify): [ ] Emergency Leave ( ) Within the Philippines
Proofs In Case of Sick Leave ( ) Excused, with Letter & ____________________ Reason/s:_______________ ( ) Abroad (Specify):
[ ] Compassionate Leave due to ( ) Hospital Confinement Proofs In Case of Sick Leave ( ) Excused, with Letter & ____________________
Death of Immediate Family Specify:_____________ [ ] Compassionate Leave due to ( ) Hospital Confinement Proofs In Case of Sick Leave
Member/s (Maximum of 3 Working ( ) Out-Patient Death of Immediate Family Specify:_____________ [ ] Compassionate Leave due to ( ) Hospital Confinement
Days) Specify:_____________ Member/s (Maximum of 3 Working ( ) Out-Patient Death of Immediate Family Specify:_____________
[ ] Maternity Leave (Maximum of [ ] With Reliever Days) Specify:_____________ Member/s (Maximum of 3 Working ( ) Out-Patient
105 Days) [ ] Without Reliever [ ] Maternity Leave (Maximum of [ ] With Reliever Days) Specify:_____________
( ) NSVD ( ) Others ______ [ ] With Reliever 105 Days) [ ]Without Reliever [ ] Maternity Leave (Maximum of [ ] With Reliever
( ) CS Payment/Amount:______________ ( ) NSVD ( ) Others ______ [ ] With Reliever 105 Days) [ ] Without Reliever
[ ] Paternity Leave (Maximum of 7 ( ) CS Payment/Amount:______________ ( ) NSVD ( ) Others ______ [ ] With Reliever
Days) Name of Reliever/Signature [ ] Paternity Leave (Maximum of 7 ( ) CS Payment/Amount:______________
( ) With Marriage Certificate Summary:___________________ Days) Name of Reliever/Signature [ ] Paternity Leave (Maximum of 7
( ) Without Marriage Certificate VL Used & Remaining:________ ( ) With Marriage Certificate Summary:___________________ Days) Name of Reliever/Signature
[ ] Unpaid Leave- Excused SL/EL Used Remaining:________ ( ) Without Marriage Certificate VL Used & Remaining:________ ( ) With Marriage Certificate Summary:___________________
(Maximum of 7 Days/ Year) [ ] Unpaid Leave- Excused SL/EL Used Remaining:________ ( ) Without Marriage Certificate VL Used & Remaining:________
( ) With Letter of Explanation (Maximum of 7 Days/ Year) [ ] Unpaid Leave- Excused SL/EL Used Remaining:________
[ ] Others (Specify):______________ ( ) With Letter of Explanation (Maximum of 7 Days/ Year)
[ ] APPROVED [ ] DENIED [ ] Others (Specify):______________ ( ) With Letter of Explanation
[ ] APPROVED [ ] DENIED [ ] Others (Specify):______________
JAMES TUNGPALAN, RN [ ] APPROVED [ ] DENIED
Department Head / Nurse-Manager
JAMES TUNGPALAN, RN
Department Head / Supervisor JAMES TUNGPALAN, RN
MILDRED P. ANCHETA, BSPT Department Head / Supervisor
Executive Secretary to the Hospital Administrator
MILDRED P. ANCHETA, BSPT
Executive Secretary to the Hospital Administrator MILDRED P. ANCHETA, BSPT
JURGEN RUSHELL G. RAPACON. CHA, MAN, RN Executive Secretary to the Hospital Administrator
Human Resource and Chief Nursing Officer
JURGEN RUSHELL G. RAPACON. CHA, MAN, RN
Human Resource and Chief Nursing Officer JURGEN RUSHELL G. RAPACON. CHA, MAN, RN
LILLIBETH PEREZ-RABAGO, MBAH, FPOGS, MD Human Resource and Chief Nursing Officer
Chief Finance Officer/ Hospital Administrator
LILLIBETH PEREZ-RABAGO, MBAH, FPOGS, MD
 LILLIBETH PEREZ-RABAGO, MBAH, FPOGS, MD
Chief Finance Officer/ Hospital Administrator
HRO’s Copy