APPLICATION FOR LEAVE

CSC Form No. 6 Revised 1984 1 OFFICE/AGENCY 3 DATE OF FILING

2 4

NAME POSITION

(Last)

(First) 5 SALARY (Monthly)

Middle

6 DETAILS OF APPLICATION 6 a) TYPE OF LEAVE 6 b) WHERE LEAVE WILL BE SPENT: Vacation 1. IN CASE OF VACATION LEAVE Sick Within the Philippines Personal Abroad (Specify) .. Maternity Study .. Others (Specify) __________________ 2. IN CASE OF SICK LEAVE In Hospital (Specify) . 6 c) NUMBER OF WORKING DAYS APPLIED FOR INCLUSIVE DATES Out Patient (Specify) 6 d) COMMUTATION Requested / / Not Requested ______________________ Signature of Applicant 7 7 a) CERTIFICATION OF LEAVE CREDITS as of Vacation Sick DETAILS OF ACTION ON APPLICATION 7 b) RECOMMENDATION Approval Disapproval due to Total _______________________ VICTOR D. LORENZO Administrative Officer III _____________________ District Supervisor 7 d) DISAPPROVED DUE TO:

Days

Days

Days

LEONORA S. CANDELARIA Human Resource Mgt. Officer I 7 c) APPROVED FOR: ___________ ___________ ___________ days with pay days without pay others (Specify)

_____________________________ (Signature) VICTOR D. LORENZO Administrative Officer III DATE: Nov. 2, 2004 6-Jun-05