CS Form No.

6
Revised 1984

Department of Educatio
Region VI – Western Visayas
SCHOOLS DIVISION OF ILOILO
La Paz, Iloilo City

________________________________________________________________________________________________
APPLICATION FOR LEAVE
1. OFFICE/AGENCY 2. NAME (Last) (First) (Middle)
Dep. Ed., Division of Iloilo ESTILO STEVEN KEITH MUEDA
3. DATE OF FILING 4. POSITION 5. SALARY(Monthly)
DECEMBER 26, 2019 NURSE II P 30, 531.00
DETAILS OF APPLICATION
6. A) TYPE OF LEAVE: 6. B) WHERE LEAVE WILL BE SPENT:
(1) IN CASE OF VACATION LEAVE
Vacation Within the Philippines
To seek employment Abroad (Specify)__________________
Others (specify) _______ (2) IN CASE OF SICK LEAVE
___________________ _ In hospital (Specify) _______________
Sick ________________________________
Maternity / Paternity Out Patient
Others (Specify)
_____________________________

6. C) NUMBER OF WORKING DAYS APPLIED FOR. 6. D) COMMUNICATION

APPLIED FOR_____1(ONE)__ _ Request
INCLUSIVE DATES ____DECEMBE R23, 2019___ Not Requested
_______________________________
Signature of Applicant
Employee Number 6385254
Date of Original Appointment March 15, 2018

DETAILS OF ACTION ON APPLICATION

CERTIFICATION OF LEAVE CREDITS RECOMMENDATION
7. a) CERTIFICATION OF LEAVE CREDITS 7. b) RECOMMENDATION
As of Approval

Vacation Sick CTO/COC PL Others TOTAL Disapproval

EARNED ___________________________
SPENT ___________________________
BALANCE

_________________________________
JOSE MARIE T. BEDRO
Administrative Officer II
OIC-Administrative Officer V

__________________________
7. c) APPROVED FOR: 7. d) DISAPPROVED DUE TO:
_____________days with pay _____________________________
_____________days without pay _____________________________
_____________others (Specify)

________________________________
AZUCENA T. FALALES, Ph. D.
Assistant Schools Division Superintendent
Date:_________________