Civil Service Form No.
6 Annex A
Revised 2020
Republic of the Philippines
Department of Education
Region V (Bicol)
Schools Division Office
Iriga City
APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
SAGRADA NHS BELONIO ROMMEL HERRERA
MAY 10, 2024 Administrative Asst. 11 Php. 19, 923.00
3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________
6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE
Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines __________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) _____________________________
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) _____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ____________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) _____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION
12 DAYS
________________________________________ Not Requested
INCLUSIVE DATES Requested
MAY 13-17, 20-24, 28 & 29, 2024
________________________________________
(Signature of Applicant)
7. DETAILS OF ACTION ON APPLICATION
7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________
MARIA LOURDES B. BAYTA JONJON R. MONTE
___________________________________________
Administrative Officer IV School Principal I
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
MAYLANI L. GALICIA
_________________________________
Assistant Schools Division Superintendent
