CSC FORM No.

6
Revised 1998
1. OFFICE / AGENCY 2. NAME ( Last ) ( First ) ( Middle )
BJMP – CARAGA ( ________________ )
3. DATE OF FILING 4. POSITION/RANK 5. SALARY ( Monthly )

6. DETAILS OF APPLICATION

6. (a) TYPE OF LEAVE 6. b) WHERE LEAVE WILL BE SPENT

(1) IN CASE OF VACATION LEAVE
Vacation ___________ Within the Philippines
_________ To seek employment ___________ Abroad (Specify)
_________ Others (Specify)
__________ Sick (2) IN CASE OF SICK LEAVE
__________ Maternity ___________ In Hospital (Specify)
___________Others (Specify) ___________ Out Patient (Specify)

6. (c) NUMBER OF WORKING DAYS APPLIED FOR: 6.(d) COMMUTATION

______________________________________________ ___________ Not Requested
___________ Requested
INCLUSIVE DATES: ____________________________

_____________________________________
( Signature of Applicant )

DETAILS OF ACTION ON APPLICATION

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

As of ____________________________________________ ____________ Approval

____________ Disapproval due to
Vacation Sick Total ________________________________________

THELMA C ZABALA
Senior Jail Officer 3 (Authorized Official)
OIC - Chief, PRM Division
7. d) DISAPPROVED DUE TO:
7. c) APPROVED FOR:
____________________ days with pay ________________________________________
____________________ days without pay ________________________________________
____________________ others ( Specify )

Signature

REVELINA A SINDOL
Jail Senior Superintendent
Regional Director of the Jail Bureau

DATE: __________________