CSC FORM 6

Revised 1984
1. OFFICE/AGENCY 2. NAME(Last)

3. Date of Filing 4. Position

DETAILS OF APPLICATION
6. a) TYPE OF LEAVE 6. b)
/ / Vacation (1)
To seek employment
Others (Specify)
/ / Sick (2)
/ / Maternity
/ / Others (Specify)
c) NUMBER OF WORKING DAYS APPLIED FOR d)

/ / Requested
INCLUSIVE DATES:

DETAILS OF ACTION ON APPLICATIO

7. a) CERTIFICATION OF LEAVE CREDITS b)
AS OF

Vacation Sick Total

 WENNIE O. GAELA
Administrative/Personnel Officer

c) RECOMMENDATION
/ / Approved

MERTHEL M. EVARDOME, CESO VI

Schools Division Superintendent
d) APPROVED FOR e)
days with pay
days without pay
others (Specify)

Signature

(Authorized Official)

NOTE:
1. Application for vacation leave or sick leave for one full day or more shall be made on this
duplicate.
2. Application for vacation leave shall be filed in advace or whenever possible (5) days befo
3. Application for sick leave filed in advance or exceeding five days shall be accompanied b
medical certificate was not availed an affidavit should be executed by the applicant.
4. An eemployee who is absent without approved leave shall be not entitled to receive hi
 of his unauthorized leave of absence.
5. An application for leave of absence of thirty (30) calendar days shall be accompanied by
property accountability.
 APPLICATION FOR LEAVE

(First) (Middle)

5. Salary (Monthly)

PLICATION
WHERE LEAVE WILL BE SPENT
IN CASE OF VACATION
/ / within the Philippines
/ / Abroad (Specify)
IN CASE OF SICK LEAVE
/ / In Hospital (Specify)
/ / Outpatient (Specify)
COMMUTATION

/ / Not Requested

Signature of Applicant
ON APPLICATION
RECOMMENDATION
/ / Approved / / Disapproved due to
 GELYN D. DE CASTRO, Ed. D.
Principal II

/ / Disapproved

OME, CESO VI
uperintendent
DISAPPROVED DUE TO

Official)

e shall be made on this form to be accomplished atleast in

possible (5) days before going on such leave.

shall be accompanied by a medical certificate. In case of
by the applicant.
ot entitled to receive his salary corresponding to the period
all be accompanied by a clearance from money and
 C L E A RA N C

TO WHOM IT MAY CONCERN:

This is to certify that the undersign

Her/his last day of service in our school is

Issued upon request of the interes

ROXAN O. PACLIBARE
( Designated Property Custodian )

GELYN D. DE CAST
Principal
L E A RA N C E

Date

he undersigned is cleared of money and property accou

of the interested party for purpose or purposes it may se

EVELYN P. NASE
( School Treasurer )

YN D. DE CASTRO, Ed. D.
Principal II
erty accountabilities.

s it may serve.