Republic of the Philippines

Department of Education
Region V
Division of Camarines Sur
Calabanga West District
UNION ELEMENTARY SCHOOL
San Lucas, Calabanga, Camarines Sur 4405

_________________________
Date

LOIDA N. NIDEA, CESO V

Schools Division Superintendent
Division of Camarines Sur
Freedom Sports Complex
San Jose, Pili, Camarines Sur
(Thru Channel)

Dear Madam:

I have the honor to apply for ( 105 days ) one hundred five days calendar/working
days sick/maternity/vacation leave of absence with/without pay effective
________________________________________ inclusive charge to my service credits earned per
supporting papers duly attached.

Enclosed are the CSC Form 6 , 41 and other pertinent papers duly accomplished.

Very truly yours,

JULIE ANN C. SALAZAR

013- 007- 4820422
CP.NO. 09460468677

APPROVED:

REBECCA A. DUMALASA
School Principal II
CS Form 6

APPLICATION FOR LEAVE

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

Dep.Ed. Division of Camarines Sur SALAZAR JULIE ANN CERDEÑA
3. Date of Filing 4. Position 5. Salary (Daily)
TEACHER 1
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 CAS EOF SICK LEAVE

( / ) Maternity ( ) Out Patient (Specify)
( ) Others (Specify)

7. NUMBER OF WORKING DAYS APPLIED (6) COMMUTATION

FOR MATERNITY LEAVE ( ) Requested ( ) Not Requested
INCLUSIVE DATES: FEBRUARY , 2022 TO
MAY , 2022

Signature of Applicant

DETAILS OF ACTION ON APPLICATION

7. (a) CERTIFICATION OF LEAVE CREDITS

as of ________________________ (b) RECOMMENDATION
Vacation Sick Total ( / ) Approval
Days Days Days ( ) Disapproval due to ________________

Personnel Officer
REBECCA A. DUMALASA
School Head
Authorized Official

APPROVED DISAPPROVED DUE TO:

days with pay
days without pay
others (Specify)

Signature
Date:
CECILE C. FERRO
Assistant Schools Division Superintendent
Authorized Official

INSTRUCTION

1. Application for vacation or sick leave for full day or more shall be made on this form accomplished at least in duplicate.
2. Application for leave shall be filed in advance or where possible days before going on sick leave.
3. Application for sick leave file in advance or exceeding five (5) days shall be accompanied by medical certificate. In case medical consultant was not
availed of an affidavits should be executed by the applicant.
4. An employee who is absent without approved leave shall not be entitled to received his/her salary corresponding to the period on his/her authorized
leave of absence.
5. An application for leave of absence for thirty (30) Calendar Days or more shall be accompanied by clearance form money and properties of
responsibility
 Republic of the Philippines
Department of Education
Region V
Division of Camarines Sur
CALABANGA WEST DISTRICT

_____________________
Date

UNION ELEMENTARY SCHOOL

Name of School

CERTIFICATION

TO WHOM IT MAY CONCERN:

This is to certify that JULIE ANN C. SALAZAR, Teacher I, of this school / District, has been
cleared of all money and property responsibility in this School and/ or District as of today ______________
thus complete clearance in this school/ District is hereby granted. Consequently, turnover of property
responsibility has been according made to his/ her successor in the service ( In case of Head of School/ District
Supervisor/ Chief Cluster Principal an Invoice of Receipt for property turnover is required).However the above
mentioned person has completely accounted for all government property received by her during her tenure of
service in this School/ District.

FRANCIS BRENN C. HERNANDEZ LEONARDO R. BELDUA JR.

School Property Custodian School Principal II

WILLIAM A. PANTE MARITES ALBISO ALBINO S. MORIŇO

District Property Custodian CAWDISTEA Treas. Public Schools District Supervisor

a. Latest and complete permanent address: Baras, Canaman, Camarines Sur.

b. Amount paid for the property losses to School Head, District Property Custodian,
District Supervisor (OIC,etc.) ___________________________________________
c. Date of payment; ______________________________________________________
d. Purpose of clearance: Travel Abroad___ ____________________
e. Other information:_____________________________________________________
f. Transfer to what school: ________________________________________________
g. Address: _____________________________________________________________
h. Other matters settled, etc.: _______________________________________________

JULIE ANN C. SALAZAR

Name & signature of person seeking clearance
Form 41

PHILIPPINE CIVIL SERVICE

-oOo-
MEDICAL CERTIFICATE

I hereby waiver all rights and privileges pertaining to professional confidence between physician and
patient and the physical accomplishing this form is authorized to answer in detail all question contained hereto.

__________________
(Signature of patient)
………………………………………………………………………………………………………

(Attending Physician should fill in the blanks below; every detailed should be answered to avoid delay
action of application for leave submitted by patient) JULIE ANN C. SALAZAR of the office of DepEd
.Calabanga, Camarines Sur, having made application for leave of absence on account of illness, I do hereby
certify that I was the applicant’s actual physician from___________________ to ________________ inclusive
and from my professional knowledge of the case the following statements are submitted as contemplated by the
provision of Section 8 Civil service Rule XVI.

Name of disease or Disability__________________________________________________________________

______________________________________________________________________________________
…………………………………………………………………………………………………………………….......

Etiology: under this heading in addition to given full etiology on the disease or disability, the physician must
either state the language of the executive order. There is no indication whatsoever that the disease name was not
to immoral or vicious habits or give indications.
………………………………………………………………………………………………………

History:__________________________________________________________________________________
________________________________________________________________________________________

Description:
_________________________________________________________________________________________
______________________________________________________________________________________

The laboratory test or examination ________was made in this case the applicant was confined in his/her house/
hospital from ___________________2022 to___________________2022 inclusive and that his/her claim is
meritorious.

Affix Documentary Stamp

Signature:________________________
Official Address:__________________
________________________________
 Republic of the Philippines
Department of Education
Region V
Division of Camarines Sur
Calabanga West District
UNION ELEMENTARY SCHOOL
San Lucas, Calabanga, Camarines Sur 4405

PERTINENT PAPERS
for

Maternity Leave
 JULIE ANN C. SALAZAR
112497 UNION ELEM. SCHOOL
San Lucas, Calabanga, Camarines Sur

013- 07- 4820422

CP NO. 09460468677/09075119973