CSC Form 6

Revised 1984
APPLICATION FOR LEAVE
1. Office/Agency 2. Name (Last) (First) (Middle)
Department of Education
3. Date of Filing 4. Position 5. Salary (Monthly)
, 201
DETAILS OF APPLICATION
6. a) TYPE OF LEAVE 6. b) WHERE LEAVE WILL BE SPENT:
[ ] Vacation (1) IN CASE OF VACATION LEAVE
[ ] To seek employment [ ] Within the Philippines
[ ] Others (Specify) [ ] Abroad (Specify) ___
(2) IN CASE OF SICK LEAVE
[ ] Sick [ ] In Hospital (Specify)
[ ] Maternity ______________________________
[ ] Others (Specify) [ ] Out Patient (Specify) _____________________________
_________________________
COMMUTATION
[ ] Special Privilege Leave (Specify)
[ ] Requested [ ] Not Requested
6. c) NUMBER OF WORKING/CALENDAR DAYS APPLIED FOR:
days
____________________________________________
Inclusive Dates: , 201
(Signature of Applicant)
DETAILS OF ACTION ON APPLICATION
7. a) CERTIFICATION OF LEAVE CREDITS 7. b) RECOMMENDATION
[ ] Approval
As of _____________________________________
[ ] Disapproval due to
VACATION - SICK = TOTAL
________________________________
Balance : ______________ - ___________ = _______
Less:
_______________________________________________
This leave _____________ - ___________ = ________

Balance: _____________ + ___________ = ________ CECILIA O. ESPARAGOZA

Principal II
GRACE S. GENOVATA
Administrative Officer IV
BENITO G. BACLAGON, JR.
Administrative Officer V

8. A. APPROVED FOR: 9. (d) RECOMMENDATION:

__________________ Days with pay
__________________ Days without pay
____________________________________________________
__________________ Others (Specify)

REYNALDO G. GICO, EdD., CESO VI

Asst. Schools Division Superintendent
Officer-in-Charge
INSTRUCTION
1. Application for vacation or sick leave for one (1) day or more shall be made on this form at least in duplicate.
2. Application for leave shall be filed in advance or whenever possible five (5) days before going on such leave.
3. Application for sick leave filed in advance, or exceeding (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 be entitled to receive his salary corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for 30 calendar days or more shall be accompanied by clearance from money and property accountabilities.