CSC Form No.

6
Revised 1998

APPLICATION FOR LEAVE Employee No: _____________

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

3. DATE OF FILING 4. POSITION 5. SALARY

6. DETAILS OF APPLICATION
6.1 TYPE OF LEAVE 6.2 WHERE LEAVE WILL BE SPENT:

VACATION IN CASE OF VACATION LEAVE

To seek employment Within the Philippines
Others (Specify)______________ Abroad (Specify)

√√ Sick IN CASE OF SICK LEAVE

Maternity In Hospital (Specify)
Others (Specify) ___________ Out Patient (Specify)

6.3 Number of Working Days Applied for: 6.4 COMMUTATION

_______________________
Not Requested
Inclusive Dates: Requested
________________________

(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.1 CERTIFICATION OF LEAVE CREDITS 7.2 RECOMMENDATION

As of Approval
Vacation Sick Total
Disapproval due to

_______________________
PERSONNEL OFFICER (Authorized Officer)
7.3 APPROVED FOR: 7.4 DISAPPROVED DUE TO:
day/s with pay
day/s without pay
others (Specify)

(Signature)

(Authorized Official)

Date: ______________