APPLICATION FOR LEAVE

1. OFFICE/AGENCY 2. NAME (Last) (First) (Middle)

DOH LA ROSA ANNIE DELA PEA
3. DATE OF FILING 4. POSITION 5. SALARY (Monthly)
APRIL 12, 2017 DMO V
DETAILS OF APPLICATION
6. a.) TYPE OF LEAVE b.) Where leave will be spent:
[ ] VACATION
[ ] To seek employment 1. In case of Vacation Leave:
Others (Specify)___________________ [ ] Within the Philippines
[ / ] SICK [ ] MATERNITY
[ ] TERMINAL [ ] PATERNITY _________________________
SPECIAL PRIV. (Pls. check approp. Box) (Forwarding Address)
[ ] Govt./Personal Transaction [ ] Abroad (Specify) _______________
[ ] Hospitalization [ ] Accident
[ ] Enrolment [ ] Graduation 2. In case of Sick Leave:
[ ] Relocation [ ] Calamity [ ] In Hospital (Specify)_____________
[ ] Birthday [ ] Out Patient (Specify) ______________
[ ] Wedding/Wedding Anniversary Leave d.) Commutation:
[ ] OTHERS (Specify) ________ [ ] Requested
[ ] Not Requested

c.) NO. OF WORKING DAYS

APPLIED: 1
Inclusive Dates: APRIL 11, 2017 (Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

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

[ ] APPROVAL as of_________________________
[ ] DISAPPROVAL DUE TO: VACATION SICK
Less this leave :________ _________
ANNABELLE P. YUMANG, MD,MCH Balance :________ _________
(Authorized Official)

C) APPROVED FOR: 7. d.) DISAPPROVED DUE TO:

______________Days With Pay ________________________________
______________Days Without Pay ________________________________
______________Days w/ HALF/FULL Pay _________________________________
______________OTHERS (Specify) _________________________________

BY AUTHORITY OF THE SECRETARY OF HEALTH:

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