Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
Lingayen

APPLICATION FOR LEAVE

For Teaching and Non-Teaching Personnel (1-5days)

CSC Form 6 Revised 1984 NAPOLITANO MARILYN O.

1. Office Agency 2. Name (Last) (First) (M.I.)

JANUARY 16, 2019 TEACHER III 22, 224. 00

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

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

(1) In case of vacation leave
Vacation within the Philippines_________
Others (Specify)___________ Abroad (Specify)____________
Sick_____________________ (2) In case of Sick Leave
Maternity _________________________ in Hospital (specify) _________________
√ Others (specify)_____PAG IBIG UPDATE______ Out Patient (specify) Influenza
c. Number of working days d. Communication
applied for ____1__ days
Inclusive Dates √ requested not requested
JAN. 18, 2019- JAN. 18, 2019

__________________________________
Signature of Applicant

7. a) Certification of Leave Credits b) Recommendation

as of ___________________ Approval __________________________
Disapproved due to __________________

Vacation Sick Total

Days Days Days

c) Approved for d) Disapproved due to

_______________________ days with pay _______________________________________

_______________________ days without pay _______________________________________
_______________________ others _______________________________________

APPROVED:
DOLJEAN B. FERNANDEZ, HT-III
OIC-Office of the Principal

INSTRUCTION
1. Application for vacation or sick leave for one (1) full day or more shall be made on the form and accomplish at least in triplicate.
2. Application for vacation 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 succeeding five (5) days shall be accompanied by a medical certificate in case
medical consultation was not availed an affidavit should be filled by the applicant.
4. An employee who is absent without approved leave shall not be entitled to receive his/her salary corresponding to the period of his
unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by a clearance from money and
property accountabilities and for endorsement addressed and duly approved by the Regional Office.