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________________________________________________________________________________

1. OFFICE /AGENCY

2. NAME (Last)

(First)

(Middle)

______________________________________________________________________________
3. Date of filing
4. Position
5. Salary (Monthly)
______________________________________________________________________________
DETAILS OF APPLICANT
______________________________________________________________________________
6. A)TYPE OF LEAVE
6. B)WHERE LEAVE BE SPENT
( )Vacation
1. In case of vacation leave
( )To seek employment
( )within the Philippines
( ) Others (specify)
( ) Abroad (specify)
( ) Sick
2. In case of sick leave
( )Maternity
in the hospital (specify)_______________
( ) Others (specify)
6. C. NUMBER OF WORKING DAYS
Applied for _____________
( )Out of Patient______________________
Inclusive dates _____________
___________________
6.D. COMMUTATION:
( )Requested
( )Not Requested
___________________________
Signature of Applicant
7. B) RECOMMENDATION

7. A.) CERTIFICATION OF LEAVE CREDITS

As of _______________________
Vacation
Sick
Total
( )Approved
____________
________
________
( )Disapproved due to
Less ____________
________
________
Balance___________
________
________

 c c 
Administrative Officer III
7.C) RECOMMENDING APPROVAL
_________ days/s with pay
_________ days/without pay
_________ others (specify)

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Principal I
7. D) DISAPPROVED TO:
__________________________
__________________________
__________________________


c c cc 
Schools Division Superintendent

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region 02
DIVISION OF QUIRINO
Cabarroguis


 

IBM Acctg/Payroll Services Division
DECS Complex, Meralco Avenue
Pasig City Philippines

The Application for leave of absence on C.S. Form 6 of ____________________

Division of Quirino, Submitted to this office is hereby approved in accordance with Executive
Order No. 284 dated January 19, 1971 as follows:

_____________________ Absence due to illness, offset by vacation service credits.

_____________________Absence due to illness, payment of which should be

Withheld.
_____________________ Absence due to personal reasons for which deduction is Salary should
be made.

_____________________ Absence due to Maternity Leave of Absence with HALF/FULL PAY.

For the Secretary of Education:




Copy Furnished:
___________________
___________________


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Schools Division Superintendent