Republic of the Philippines

DEPARTMENT OF HEALTH
Regional Office 3
Provincial DOH Office-Bataan

APPLICATION FOR LEAVE

HUMAN RESOURCE FOR HEALTH
PROVINCE OF BATAAN

PROGRAM: ____________________________

NAME: ____________________________

MUNICIPALITY: ____________________________

DATE OF FILING: ____________________________

DETAILS OF APPLICATION

TYPE OF LEAVE:

SICK

COMPENSATORY TIME-OFF DOH LGU (1) ___ (2) __

Pls. indicate the date and title of the activity conducted:

_____________________________________________________________

ABSENT

VACATION WHERE LEAVE BE SPENT WITHIN THE PHILIPPINES

ABROAD; Specify________________
EMERGENCY

NUMBER OF WORKING DAYS APPLIED:

DAY/S: ____________________________

INCLUSIVE DATES: ____________________________

__________________________
Signature of Applicant
Recommendation

_____________________ ________________________
City/Municipal Health Officer Development Management Officer

APPROVED BY:

___________________________________
FRANCISCO D. HERMOSO III, MD
DMO V - Provincial DOH Officer - Bataan
Email address: phto_bataan2010@yahoo.com