CSC Form No.

6
Revised 1984 APPLICATION FOR LEAVE
1. OFFICE/AGENCY 2. NAME (Last) (First) (Middle)

3. DATE OF FILING 4. POSITION 5. SALARY

6. DETAILS OF APPLICATION

6.1 TYPE OF LEAVE 6.2 WHERE LEAVE WILL BE SPENT:

X Vacation IN CASE OF VACATION LEAVE

To seek employment Within the Philippines
Others (Specify) Abroad (Specify)

Sick IN CASE OF SICK LEAVE

In Hospital (Specify)
Maternity Out Patient (Specify)

X Others (Specify) 6.4 COMMUTATION

xX Forfeitable Leave
XX
6.3 NUMBER OF WORKING DAYS APPLIED FOR Not Requested
1 (one) day Requested
INCLUSIVE DATES

(Signature of Applicant)
7. DETAILS OF ACTION APPLICATION
(To be filled-up by the Employees' Leave Division)

7.1 CERTIFICATION OF LEAVE CREDITS 7.2 RECOMMENDATION

As of Approval
Vacation Sick Total Disapproval due to
___________________________
Days Days Days

Personnel Officer
7.3 APPROVED FOR: 7.4 DISAPPROVED DUE TO:

days with pay

days without pay
others (Specify)

(Signature)

EXECUTIVE JUDGE