CSC Form No.

6
Revised 1984
APPLICATION FOR LEAVE

1. OFFICE/AGENCY

2. NAME (Last)

(First)

3. DATE OF FILING

4. POSITION

5. SALARY (Monthly)

6. a) TYPE OF LEAVE

6. b) WHERE LEAVE WILL BE SPENT

Vacation
To seek employment
Sick
Maternity
Others (Specify)

(Middle)

(1) IN CASE OF VACATION .LEAVE

Within the Philippines
Abroad (Specify)
(2) IN CASE OF SICK LEAVE
In hospital (Specify)
Out patient (Specify)

Special Leave
c) NUMBER OF WORKING DAYS APPLIED FOR

D) COMMUNTATION
Requested

INCLUSIVE DATES

Not requested

Signature of Applicant

DETAILS OF ACTION OF APPLICATION

7. a) CERTIFICATION OF LEAVE CREDITS
as of

7. b) RECOMMENDATIONS
Approval
Disapproval due to

Personnel Officer

7. c) APPROVED FOR

Days with pay

Days without pay
Others (Specify)

Officer-In-Charge

7. d) DISPPAROVAL DUE TO

Date: