APPLICATION FOR LEAVE

OFFICE/AGENCY EMPLOYEE NO. (LAST) (FIRST) (MIDDLE)

DATE OF FILING POSITION SALARY(Monthly)

DETAILS OF APPLICATION
T Y P E O F L E AV E W H E R E L E AV E W I L L B E S P E N T
VA C AT I O N
I N C A S E O F VA C AT I O N L E AV E
Others (Specify)
Wi t h i n t h e P h i l i p p i n e s
Abroad (specify)
e.g. SPL
SICK
I N C A S E O F S I C K L E AV E
M AT E R N I T Y
In Hospital (Specify)
PAT E R N I T Y

N U M B E R O F W O R K I N G D AY S
APPLIED FOR: Out Patient (Specify)
I N C L U S I V E D AT E S :

FROM TO
MM DD YYYY MM DD YYYY

C O M M U TAT I O N
Requested
Not Requested

(Signature of Applicant)
DETAILS OF ACTION ON APPLICATION
C E RT I F I C AT I O N O F L E AV E R E C O M M E N D AT I O N
AS OF Approved

VA C AT I O N SICK TO TA L Disapproved due to

Subject to reconciliation with HRMO on the

correctness of leave credit balances
( P e r s o n n e l O ff i c e r ) ( A u t h o r i z e d O ff i c i a l )
APPROVED FOR: D I S A P P R O V E D D U E TO :

days with pay

days without pay

others (specify)

( A u t h o r i z e d O ff i c i a l )