APPLICATION FOR LEAVE

CSC Form No.

Revised 1984

1. OFFICE/AGENCY

2. NAME

3. DATE OF FILING

(Last)
4. POSITION

(First)
(Middle)
5. SALARY

DETAILS OF APPLICATION
6. (a) TYPE OF LEAVE
______ Vacation
______ To seek employment
______ Sick
______ Maternity
______ Others (Specify)___________________
6. (c) Number of working days applied for:
_______________________________________
INCLUSIVE DATES _____________________
_______________________________________.

6. (b) WHERE LEAVE WILL BE SPENT

1. IN CASE OF VACATION LEAVE
__________ Within the Philippines
__________ Abroad (Specify)
2. IN CASE OF SICK LEAVE
__________ In hospital (Specify) ____________
________________________________________
__________ Out Patient (Specify) ____________
6. (d) Commutation
_______Requested _______Not Requested
______________________________________
(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

7. (A) CERTIFICATION OF LEAVE CREDITS
as of ________________________________

Vacation

Sick

7. (B) RECOMMENDATION
_________________ Approval
_________________ Disapproval due to _________
___________________________________________

Total

Engr. ERNANI C. TAN

Municipal Mayor
(Authorized Official)

MILA ALLAREY-BENDIOLA
Human Resource Management Officer II

7. (C) APPROVED FOR

_________days with pay
_________days without pay
_________other (specify)

7. (D) DISAPPROVED DUE TO:

__________________________________
__________________________________

_______________________________________
(Signature)
Engr. ERNANI C. TAN
Municipal Mayor
(Authorized Official)
Date:_______________________