School I.

D:
DEPARTMENT OF EDUCATION _________________
Region V
Division of Camarines Sur Contact No.:
LIBMANAN NORTH DISTRICT _________________
Libmanan, Camarines Sur

_________________________, 20______

The Public Schools District Supervisor

Libmanan North District
Libmanan, Camarines Sur

Sir:

I have the honor to apply for _________________________ LEAVE OF ABSENCE (with or

without) pay effective __________________________ to _______________________________.

Attached herewith are my CS Form 6 and 41 duly authenticated.

Very truly yours,

________________________________
Signature Over Printed Name

Employee No. ____________________

Salary Php _______________________
Nature of Leave __________________
Effectivity _______________________

1st Indorsement
LIBMANAN NORTH DISTRICT
Libmanan, ___________________, 20______

Respectfully forwarded to the Schools District Supervisor, Libmanan North District, Division of
Camarines Sur recommending favorable approval.

Recommending Approval:

____________________________
Head of School

APPROVED:

TERESITA S. HABER
Public Schools District Supervisor
C.S. Form 6

APPLICATION FOR LEAVE

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

3. DATE OF FILING 4. POSITION 5. MONTHLY SALARY

DETAILS OF APPLICATION
6. (a)TYPE OF LEAVE 6. (b) WHERE LEAVE WILL BE SPENT
/ / Vacation (1) IN CASE OF VACATION LEAVE
/ / To seek employment / / Within the Philippines
/ / Others (specify) ____________ / / Abroad (specify) ___________
______________________ ______________________
/ / Sick (2) IN CASE OF SICK LEAVE
/ / Maternity / / In Hospital (specify) ________
/ / Other (specify) _________________ _____________________
______________________ / / Out-patient (specify) ________
_____________________
6. (c) NUMBER OF WORKING DAYS 6. (d) COMMUTATION
APPLIED FOR ______________________
INCLUSIVE DATES __________________ / / Requested / / Not Requested
_____________________________

__________________________
Signature of Applicant

Employee No. _______________

DETAILS OF ACTION ON APPLICATION

7. (a) CERTIFICATION OF LEAVE CREDITS 7. (b) RECOMMENDATION
As of ___________________________ / / Approval
/ / Disapproved due to ______________
__________________________

________________________________
(Authorized Official)

_______________________________ ________________________________
(Personnel Officer)

7. (c) APPROVED 7. (d) DISAPPROVED DUE TO

____________ days with pay
____________ days without pay ________________________________
____________ others (specify)

MARILYN V. MARCO
Authorized Official

INSTRUCTIONS
1. Application for vacation or sick leave for one full day or more shall be made on this form and be accomplished at least
in duplicate.
2. Application for vacation leave shall be filed in advance or possible five (5) days before going on such leave.
3. Application to sick leave shall be filed in advance or exceeding five (5) days shall be accomplished with medical
certificate. In case medical consultation was not availed of, an affidavit must be executed by the applicant.
4. An employee who is absent without the approved of leave shall not be entitled to receive his/her salary corresponding
to the period of his/her unauthorized leave of absence.
 5. An application for leave of absence for thirty (30) calendar days or more shall be accomplished with a clearance for
money and property responsibilities.

CSC Form No. 6 (Revised 1985) APPLICATION FOR LEAVE

TYPE OF LEAVE
Signature _______________________________
VACATION Within the Philippines
Name _________________________________ Abroad (specify)
Position ________________________________ _________________

Monthly Salary __________________________ SICK Out-patient (specify)

_________________
Office / Division _________________________
Date of Filing ____________________________ In Hospital (specify)
_________________
No. of working days applied for _____________
MATERNITY _________________________
Inclusive Dates __________________________
OTHER (specify) _____________________

COMMUTATION: ACTION ON APPLICATION

Requested Not requested Recommending
Approved
FOR PERSONNEL USE ONLY
Leave Credits as of V.L. S.L. Total Disapproval due to _________________

Less: THIS LEAVE

Leave Balance
--------------------------------------------------------------
Certified by: Approved for: Disapproved due to

_________________Days w/ Pay_________________
________________Days w/o Pay_________________
MYLLAN B. TOLEDANA
Administrative Officer V

CSC Form No. 6 (Revised 1985) APPLICATION FOR LEAVE

TYPE OF LEAVE
Signature _______________________________
VACATION Within the Philippines
Name _________________________________ Abroad (specify)
Position ________________________________ _________________

Monthly Salary __________________________ SICK Out-patient (specify)

_________________
Office / Division _________________________
Date of Filing ____________________________ In Hospital (specify)
_________________
No. of working days applied for _____________
MATERNITY _________________________
Inclusive Dates __________________________
OTHER (specify) _____________________

COMMUTATION: ACTION ON APPLICATION

Requested Not requested Recommending
FOR PERSONNEL USE ONLY Approved
Leave Credits as of V.L. S.L. Total Disapproval due to _________________

Less: THIS LEAVE

Leave Balance

Certified by: --------------------------------------------------------------

Approved for: Disapproved due to

_________________Days w/ Pay_________________

MYLLAN B. TOLEDANA ________________Days w/o Pay_________________

Administrative Officer V

PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATION

I herby wave all rights and privileges pertaining to professional confidence between physician
and patient, and the physician accomplishing this form authorized to answer to in detail all questions
contained herein.

_________________________
Signature of Patient

N.B. (Attending physician should fill in the blanks below every detail should be answer to avoid delay in
action on the application submitted by the above patient.

______________________________ of the Department of Education, having made

application for leave of absence on account of illness, I do hereby certify that I will be applicants’ actual
attending physician from ____________________________ to ____________________________,
inclusive, and from my professional knowledge of the case, the following statement are submitted, as
contemplated by the provisions of Section B of Civil Service Rule XVI.

NAME OF DISEASE OR DISABILITY: __________________________________________

NATURE OF DISEASE OR DISABILITY: ________________________________________

___________________________________________________________________
___________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------
ETIOLOGY: Under this heading, in addition to giving full etiology of the disease or disability
the physician must either state in the language of the Executive Order. THERE ARE NO INDICATIONS
WHATSOEVER THAT THE DISEASE NAMED WAS DUE TO IMMORAL OR VICIOUS HABITS, or give
indications.
_________________________________________________________________________________
_________________________________________________________________________________

HISTORY: ________________________________________________________________

DESCRIPTION: ___________________________________________________________
______________________________________________________________
______________________________________________________________

A laboratory test was __________ made on the case.

The applicant was confined in (his/her house) Hospital from
_____________________________ to _____________________________ inclusive.
 I hereby certify that the above statement are complete and true in every detail and that in
consequence of the disease / disability above specified the applicant was ill and unable to be duly on
account of illness from _____________________________ to _____________________________
inclusive, and that his/her claims is meritorious.

_________________________
Signature
Affix Documentary Stamp

_________________________
_________________________ Address
Date

Department of Education
Region V
Division of Camarines Sur
LIBMANAN NORTH DISTRICT
Libmanan, Camarines Sur

_________________________, 20______

The Schools Division Superintendent

Division of Camarines Sur
Freedom Sports Complex
San Jose, Pili, Camarines Sur
(Thru Channels)

Madam:

I have the honor to request for reinstatement from ______________________________ leave

of absence effective _________________________, 20__________.

I was on __________________________________ leave from

______________________________ to ____________________________.

Attached herewith are my CS Form 211 and _________________________________ of my

child duly accomplished and authenticated.

Very truly yours,

____________________________________
Station Code No. _____________________
Employee No. ________________________
Status ______________________________
Salary ______________________________
 1st Indorsement
LIBMANAN NORTH DISTRICT
Libmanan, _______________________, 20______

Respectfully forwarded to the Schools Division Superintendent for the Division of Camarines
Sur, San Jose, Pili, Camarines Sur, recommending approval.

TERESITA S. HABER
Public Schools District Supervisor

CSC FORM NO. 211 (1997) PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE
For Employment

INSTRUCTION

1. This medical certificate should be accomplished by a government physician.

2. Attached this certificate to original appointment and reinstatements.

FOR THE PROPOSED APPOINTMENT

NAME (Last, First, Middle or if married woman, Maiden Name) AGENCY

ADDRESS PROPOSED POSITION

AGE SEX CIVIL STATUS

Pre-employment Medical Physical Test

1. Blood Test
2. Urinalysis
3. Chest X-ray
4. Drug Test
5. Neuro-Psychiatric Examination (if necessary)

NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THE FORM

FOR THE PHYSICIAN

I hereby certify that I personally examined the

above mentioned individual and found her/him to be Documentary Stamp
physically and medically fit/unfit for employment.
SIGNATURE OF PHYSICIAN CERTIFICATE OTHER INFORMATION ABOUT
NUMBER THE APPOINTEE
OFFICIAL DESIGNATION HEIGHT WEIGHT
(Bare Foot) (Stepped)

AGENCY DATE EXAMINED

DEPARTMENT OF EDUCATION
Region V
Division of Camarines Sur
LIBMANAN NORTH DISTRICT
Libmanan Camarines Sur

_________________________________

_____________________
Date
To Whom It May Concern:

THIS IS TO CERTIFY THAT __________________________________________________

(Name of Teacher / Employee)
________________________________ has been cleared of all money and property responsibility in
(Designation)
______________________________________ School, ___________________________________
District, this ______ day of ________________________, 2012, hence complete clearance is hereby
granted. Consequently, turn-over of property has been made accordingly to his/her successor or to
authorized person/school personnel in-charge of the property or money matters. (In case of school head,
district supervisor, principal invoice receipt for property turned over is required). Moreover, the above-
named person has completely accounted for all government property he/she received during his/her
tenure of service

__________________________ __________________________ ______________________

School Property Custodian School Finance Officer School Head, OIC, etc.

ISMAEL O. ONAN TERESITA M. CUESTA TERESITA S. HABER

District Property Custodian District Finance Officer Public Schools District
Supervisor

a. Latest and complete permanent address ___________________________________________

 _________________________________________________________________________
b. Amount paid for Property Losses to School Head / School/District Property Custodian / District
Supervisor / Chief Cluster Principal _________________________________
c. Date of Payment _________________________________
d. Purpose of Clearance _________________________________________________________
(Retirement, Transfer, Resignation, etc.)
e. Other information _____________________________________________________________
Transfer to what school __________________________________________________________
Address _______________________________________________________________________
Other matters settled, etc. ________________________________________________________
___________________________________________________________________________

___________________________________________
(Name and Signature of Person Seeking Clearance)