./.

FORM 6
(Revised as of March 2009)
1.0FFICEIDISTRICT
CALBAYOG
DepEdI
3. DATE OF FILING:

M.I.

FIRST NAME:

2~LAST NAME:

III

15. SALARY:

4.PosmON:
"

7. WHERE LE~ VE"WILL BE SPENT

In case of Vacation Leave
__
_"__ within the Philippines

6. TYPE OF LEAVE
-- Vacation
To seek employment
__
Others (specify)
__

In case of Sick Leave

in hospital (specify)
__
out-patient (specify)
__

Sick
Maternity

--

__

abroad (specify)

No. of working days applied for:

" Requested

__

Commutation:

__

Not Requested

Printed Name & Signature of Applicant

Inclusive days:
"~"

8. CERTIFICATION
CREDITS
As of

OF LEAVE

9. RECOMMENDA

TIONf
I! "
Disapproval

Appr~val
Vacation

Sick

TOTAL

Days

Days

Days

!
"

!
i

!
i

+--"~-

HELEN S. RAMIREZ
School Head

EDIT A S. CANO
Administrative Officer V
10. Approved for:
__ "__ "days with pay
days without pay
days(others, specify)

ANABELLE O. YANGZON
----,-

._.-

District Supervisor

I
I
11. Disapproved

due to:

I
i
--_._----

-_-_ ..-----_.-

-"------_._.

I
DATE:

.._--

i
UBALDO O. DIOMANGAY

Chief,
SGODSuperintendent
Division
Assistant Schools

DATE
"SPECIAL ORDER
No. __ , s. 2009
No.________,
s. 2016

~=.day/s __
The application for_" __
_,___ -_,_~~---_PermanentNational
.,-is hereby approved.
This established a service credit balance of __

~"

leave of absence with/without pay on ~----~-_

Elementary Grades Teacher of

-,- day/s which maybe used to offset future absences due to illness.

By Authority of the DepEd Regional Director:

RAUL D. AGBAN , Ed. D.

"Assistant Schools Division Superintendent

Officer-In-Charge

Copy Furnished:
Teacher Concerned
Division Office File
District Office File

of