Republic of the Philippines

Municipality of Umingan
Province of Pangasinan
BARANGAY CABARUAN

OFFICE OF THE PUNONG BARANGAY

APPLICATION FOR LEAVE OF ABSENCE

Office/Unit Last Name First Name Middle Name

LGU-DCW BALMORES ERNA FERNANDEZ
Date of Filing: Position Salary/Honorarium/Month
Sept. _____2017 Day Care Worker

DETAILS OF APPLICATION
Type of Leave Cause of Leave Where leave will be spent

Sick Illness
In case of vacation leave
Vacation Personal
Within the Philippines
Maternity Vacation
Abroad, specify
Terminal Resignation
______________________________
Others (specify): Others, (specify)
In case of sick leave:
_____________________________________ __________________________________
_____________________________________ __________________________________
In hospital, specify
______________________________
No. of Days: Commutation

Inclusive Days Out patient, specify

Requested
______________________________
From To
Not Requested Others

Signature of Applicant: Approved Disapproved due to

No. of Days: _____________ ___________________________________

With Pay: _____________ ___________________________________
Without Pay: ____________ ___________________________________

Signature: ___________________________________ Signature: ___________________________________

Name: ________________________________________ Name::ROMAN F. VALERA
Position: ____________________________________ Punong Barangay