Republic of the Philippines

CAGAYAN STATE UNIVERSITY

Gonzaga, Cagayan

APPLICATION FOR LEAVE

1. Office/Agency 2. Name: Last First M.I.

CAGAYAN STATE UNIVERSITY_____________________________________________________
3. Date of Filing 4. Position 5. Salary (Monthly)

6(a) Type of Leave 6(b) Where leave will be spent

( ) Vacation
( ) To seek employment
( ) Others (specify) ________________
_____________________________
( ) Sick
( ) Maternity
( ) Others (specify) _________________
6(c) Number of working days applied:
_________________
1. In case of vacation leave
( ) within the Philippines
( ) abroad (specify) __________________
_____________________________________
2. In case of sickness
( ) in hospital (Specify) _______________
( ) out patient (specify)_______________
6(d) Commutation
( ) Requested ( ) Not requested

Inclusive Dates ___________________

_______________________________
__________________________
Signature of Applicant

DETAILS ON ACTION OF APPLICATION

7(a) Certification of Leave Credits 7(b) Recommendation
As of ___________________ ( ) Approved ____________________________
( ) Disapproved due to ____________________
Vacation Sick Total
_______ _______ _______
Less: _______ _______ _______
Balance:
_______ _______ _______ ____________________________
Authorized Official
_________________________________
Records Officer

7(c) Approved for: 7(d) Disapproved due to

_______days with pay _________________________________
_______days without pay _________________________________
_______others (specify) _________________________________

FERDINAND C. OLI, Ph.D.

Campus Executive Officer