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CSC Form 6

Revised 1998
APPLICATION FOR LEAVE
1. OFFICE/AGENCY 2. NAME Employee No.: __________
DIVISION OF SURIGAO DEL SUR DIOLA SHARON ROSE S.
Department of Education Last Name First Name M.I.
3. Date of Filing 4. Position 5. Salary
December , 2017 Senior High School Nurse II Php 27, 565.00
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)

Sick 2. In case of Sick Leave


Maternity In hospital (Specify)
Others (Specify)
Out patient (Specify)

6. C) Number of Working Days applied f6. D) Commutation


3 days X Requeste Not Requested
Inclusive Dates
December 27,28,29,2017 SHARON ROSE S. DIOLA
Signature of Applicant over Printed Name
DETAILS OF ACTION ON APPLICATION
7. A) Certification of Leave Credits 7. B) Recommendation:
as of

Vacation Sick Total Approval


Disapproval due to
day/s day/s day/s

ALICIA S. LLEGA
Personnel Officer Principal III
7. C) Approved for: 7. D) RECOMMENDATION
days with pay Approval
days without pay Disapproval due to:
Other (specify)

NORBEN T. MOLDEZ
Public School District in Charge
Date:
Signature

ELVIRA S. URBIZTONDO
Chief, SGOD
(Authorized Official)
Date: _________________
Requested

ct in Charge