CSC Form No.

6 – Revised 1988 (Accomplish in Triplicate)

APPLICATION FOR LEAVE

1. OFFICE/AGENCY 2. LAST NAME FIRST NAME MI

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

DETAILS OF APPLICATION

6.1 TYPE OF LEAVE 6.2 WHERE LEAVE WILL BE SPENT IN CASE OF

[ ] Vacation IN CASE OF VACATION LEAVE
[ ] To Seek Employment [ ] Within the Philippines
[ ] Others (specify) [ ] Abroad (specify)

[ ] Sick IN CASE OF SICK LEAVE

[ ] Maternity [ ] In Hospital (Specify)
[ ] Others (specify)
[ ] Out-Patient (Specify)

6.3 NUMBER OF WORKING DAYS APPLIED FOR: 6.4 COMMUTATION

[ ] Requested [ ] Not Requested
INCLUSIVE DATES:

(Signature of Applicant)
For Presiding Judge

DETAILS OF ACTION ON APPLICATION

(To be filled-up by the Employees' Leave Division)

7.1 CERTIFICATION OF LEAVE CREDITS 7.2 RECOMMENDATION

As of
[ ] Approval
Vacation Sick Total [ ] Disapproval

Days Days Days

(Personnel Officer)

7.3 APPROVED FOR: 7.4 DISAPPROVED DUE TO:

days with pay
days without pay
Others (specify)

HON. GREGORIO V. DELA PEÑA III

Executive Judge