CSC Form No.

6
Revised 1984

APPLICATION FOR LEAVE

1. OFFICE/AGENCY 2. NAME (Last) First Middle

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

DETAILS OF APPLICATION
6.1 TYPE OF LEAVE 6.2 WHERE LEAVE WILL BE SPENT
[ ] Vacation IN CASE OF VACANT LEAVE
[ ] To seek employment [ ] Within the Philippines
[ ] Others (Specify) FORCED LEAVE [ ] Abroad (Specify)
`
[ ] Sick IN CASE OF SICK LEAVE
[ ] Maternity [ ] In Hospital (Specify)
[ √ ] Others (Specify) Special Calamity Leave [ ] Out-Patient (Specify)
With the following attachments:
1. My Certification of damages on my house with pictures
2. S.P. Resolution of Albay No. 00215-2019 dated December 4, 2019.
6.3 NUMBER OF WORKING DAYS APPLIED FOR 6.4 COMMUTATION
One (1) Day [ ] Requested [ ] Not Requ
INCLUSIVE DATES
January 15, 2020 JUAN DELA CRUZ
(Signature of Applicant)

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

Vacation Sick Total [√] Approval

[ ] Disapproval due to

Days Days Days

Presiding Judge
(Personnel Officer)

7.3 APPROVED FOR: 7.4 DISAPPROVED DUE TO:

days with pay
days without pay
Others (specify)
 (Signature)

(Executive Judge)

PLEASE SEE INSTRUCTION AT THE BACK

INSTRUCTIONS

1. Application for vacation or sick leave for one full day or more shall be made on this
Form and to be accomplished at least in duplicate.

2. Application for vacation leave shall be filed in advance, or whenever possible five (5)
days before going such leave.

3. Application for sick leave filed in advance, or exceeding five (5) days shall be
accompanied by a medical certificate. In case medical consultation was not availed
of, an affidavit should be executed by the applicant.

4. An employee who is absent without approved leave shall not be entitled to receive
his salary corresponding to the period of his unaothorized leave of absence.

5. An applicant for leave of absence for thirty (30) calendar days or more shall be
accompanied by a clearance from money and property accountabilities.
 Middle

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five (5)

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