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CS FORM NO.

6
Revised 1984

APPLICATION FOR LEAVE


1. OFFICE/AGENCY 2. NAME (LAST) (FIRST) (M.I.)

3. DATE OF FILING 4. POSITION 5. SALARY (MONTHLY)

----------------------------------------------------------------------------------------------------------------------------- ------------------------

DETAILS OF APPLICATION

6. A) TYPE OF LEAVE B) WHERE LEAVE WILL BE SPENT


(1) IN CASE OF VACATION LEAVE
Vacation` `````````````````````Within the Philippines

Abroad (Specify)________________
To seek employment _______________________________
Other (Specify)
(2) IN CASE OF SICK LEAVE
In Hospital (specify) ____________
Sick
Maternity Out Patient (Specify) ____________
Others (Specify) _______________________________

C) NUMBER OF WORKING DAYS APPLIED FOR D) COMMUTATION


Requested Not requested

INCLUSIVE DATES:

(Signature of Applicant)

DETAIL OF ACTION ON APPLICATION

A) CERTIFICATION OF LEAVE CREDITS B) RECOMMENDATION


As of ____________ Approval
Disapproval due to
Vacation Sick Total ______________________________
______________________________

C) APPROVED FOR D) DISAPPROVED DUE TO


_____days with pay ___________________________________
_____days without pay

APPROVED: