CSC FORM NO.

6
Revised 1984

APPLICATION FOR LEAVE

2.
1. OFFICE/AGENCY Last First Middle
NAME

3. DATE OF FILING 4. POSITION 5. SALARY

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]
PRIVILEGE LEAVE
SICK
MATERNITY 2. In case of sick leave
OTHERS [specify] in hospital [specify]

6. c. NUMBER OF WORKING DAYS

APPLIED out patient [specify]
FOR
INCLUSIVE DATES
6. d. COMMUTATION
REQUESTED
NOT REQUESTED

Signature of Applicant

DETAILS OF ACTION OF APPLICATION

7. a. CERTIFICATION OF LEAVE CREDITS 7. b. RECOMMENDATION

AS
OF APPROVAL
DISAPPROVAL due to
VACATION SICK TOTAL

Recommending Approval

7. c. APPROVED FOR 7. d. DISAPPROVED DUE TO

days with pay
days without pay
Others [specify]

Signature

JESUS C. SIMBULAN
Regional Prosecutor
Authorized Official

Date