CM/ Service Form No.

6
Revised 1020 ANNEX A
1. OFFICE/DEPARTMENT 2. NAME: (Last) (First) (Middle)
DEPED / KUSAN NATIONAL HIGH SCHOOL

3. DATE OF FILING ________________ 4. POSITION _____________________I 5. SALARY _________________

6. DETAILS OIF APPLICATION

6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

O Vacation Leave (S..O. 51,Rt.le XVI Omnibus Rules iIplementing E.O. No.292) In case of Vacation/Special Privilege Leave:
O Mandatory/Forced Leave(S..O. 25, Rule XVI,Omnibus Rules Implementing E.O. No..292) O with in the Philippines
O Sick Leave (Sec.43, Rule XVI,Omnibus Rules Implementing E.O.No.292).O. O Abroad (Specify)
O Matenity Leave (RA. No.11210/IRR l!5ued by CSC,DOlE l!ndSSS) In case of Sick Leave:
O In Hospital (Specify Illness)
O Paternity Leave (RANo.8187 / CSCMCNo.71, s 1998,asamended) O out Patient (Specify Illness)
O Special Privilege Leave (Sec. 21,Rule XVI,Omnibus Rules Implementing E.O.No.
292) O Solo Parent Leave (RA No.8972 1csc MC No.8, s.2004)
O Study Leave (Sec. 68, Rule XVI,Omnibus Rules Implementfng E.O.No. 292) In case of Special Leave Benefits for Women:
O 10-Day VAWC Leave (AA No.9262 / CSC MC No. 15,s.2005) (Specify Illness)
O Rehabilitation Privilege (Sec.55,Rule XVI, Omnibus Ru!& Implementing E.O.No.29<2)
O Special Leave Benefits for Women (AA No.9710/ CSC MC No.25,s.20101 In case of Study Leave:

O Special Emergency (Calamity) Leave (CSC MC No. 2, s.2012, as amended) O completion of Master's Degree
O Adoption Leave (RA No.8552) O BAR/Board Examination Review

Other purpose:
Others:
O Monetization of Leave Credits
O Terminal Leave
6.C NUMBER OF WORK ING DAYS APPLIED: 6.D COMMUTATION
O Not Requested
O Requested
FOR INCLUSIVE DATES:

(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS
As of _________

Vacation Sick
Tota/ Earned Leave Leave
Less this
application
Balance

ROSALIE C. CADUNGON
Administrative Officer II

7.C APPROVED FOR: 7.D DISAPPROVED DUE TO: days with

pay
Days without pay
others (Specify)

JASMIN P. ISLA
Assistant Schools Division Superintendent

Republic of the Philippines

Department of Education
Region XII
Schools Division of South Cotabato
Alunan Ave., Koronadal City

APPLICATION FOR LEAVE