CSC Form No.

6
Revised 1998

APPLICATION FOR LEAVE

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

In Hospital (Specify)
Maternity Out Patient (Specify)

Others (Specify) 6.4 COMMUTATION

6.2 NUMBER OF WORKING DAYS APPLIED FOR Not Requested

Requested
INCLUSIVE DATES

(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

Days Days Days

JEREMY C. DENAMPO
Administrative Officer V (Authorized Officer)
7.3 APPROVED FOR: 7.4 DISAPPROVED DUE TO:

days with pay

days without pay
others (Specify)

(Signature)

(Authorized Official)

Date: ______________