CS Form No.

6
Revised 2001
APPLICATION FOR LEAVE

1.OFFICE/AGENCY 2. NAME (Last) (First) (Middle)

DOH CHD-NM
3.Date of Filing 4.Position(Status of Appt.) 5. Salary (Monthly)

6.a) TYPE OF LEAVE 6.b.) WHERE LEAVE WILL BE SPENT

Vacation I. In case of Vacation Leave:

To seek employment Within the Philippines (specify)______________

Others (specify)__________ Abroad (specify) _________________________

_______________________________

Sick 2. In case of sick leave

Maternity In Hospital (specify)____________________

Others (specify) Out patient (specify) ____________________

6.c.)NUMBER OF WORKING DAYS APPLIED FOR 6.d.) COMMUTATION

___________________________________
Requested
Inclusive Dates _________________
Not requested

_______________________
(Signature of Applicant)

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

As of ___________________

Approval
V
Vacation Sick Total
Disapproved due to _____________

BILLY O. LAGO JR. DR. HOLLY B. TAGO, MPH JESUSA T. MATALINES, RN, MAN
Administrative Officer I MHO/CHO DMO IV

__________________________________________________________________________________________________

7. c.)APPROVED FOR: 7.d.)DISAPPROVED DUE TO:

_______________days with pay ________________________________

_______________ days without pay ________________________________
_______________ others (specify) ________________________________

By authority of the Secretary of Health:

RAFAELITO E. PAYE, RN, MPA

(Signature of Authorized Official)
(Name of Authorized Official)

_________________________
(Date)