OFFICE ID # 013-0____
APPLICATION FOR LEAVE
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1. OFFICE/AGENCY 2. NAME (LAST) (FIRST) (MI)
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3. DATE OF FILING 4. POSITION 5. SALARY (MONTHLY)
DETAILS OF ACTION ON APPLICATION
6. TYPE OF LEAVE 6. A) WHERE LEAVE WILL BE SPENT
( ) VACATION (1) IN CASE OF VACATION LEAVE
( ) TO SEEK EMPLOYMENT ( ) WITHIN THE PHILIPPINES
( ) OTHER SPECIFY __________________________________
___________________________ ( ) ABROAD (SPECIFY) ________________
__________________________________
( ) SICK (2) IN CASE OF SICK LEAVE
( ) MATERNITY ( ) IN HOSPITAL (SPECIFY) _____________
( ) OTHER (SPECIFY) ______ __________________________________
______________________ ( ) OUT PATIENT (SPECIFY)
6. B) NUMBER OF WORKING DAYS APPLIED FOR: __________________________________
________________________________ 6. C) COMMUNICATION
INCLUSIVE DATES _______________ ( ) REQUESTED ( ) NOT REQUESTED
___________________________
(SIGNATURE OF APPLICANT)
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(DETAILS OF ACTION ON APPLICATION)
7. A) CERTIFICATION OF LEAVE CREDITS 7. B) RECOMMENDATION
AS OF _____________________________ ( ) APPROVAL
___________________________________ ( ) DISAPPROVAL DUE TO _____________
___________________________________ __________________________________
VACATION SICK TOTAL
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DAYS DAYS DAYS
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___________________________________ _______________________________________
(PERSONNEL OFFICER) (AUTHORIZED OFFICER)
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7. C) APPROVED FOR 7. D) DISAPPROVED DUE TO
_________________ DAYS WITH PAY __________________________________
_________________ DAYS WITHOUT PAY __________________________________
_________________ OTHER (SPECIFY) __________________________________
_________________________________
SIGNATURE
_________________________________
(AUTHORIZED OFFICIAL)
DATE:_______________________
________________________________________________________________________________
EFFECTIVE APRIL 1, 1995 AS PER CSC OFFICE CIRCULAR NO. SERIES 1995
