CSC Form No.

6 (Revised 1994)

APPLICATION FOR LEAVE

1. OFFICE / AGENCY
(Middle)
Bureau of Internal Revenue
3. DATE OF FILING

2. NAME (Last)

(First)

4. POSITION

5. SALARY (Monthly)

DETAILS OF APPLICATION
6. (a) TYPE OF LEAVE

6. (b) WHERE LEAVE WILL BE SENT:

[ ] Vacation

(1) IN CASE OF VACATION LEAVE

[ ] Within the Philippines
[ ] Abroad (Specify)

[ ] To seek employment
[ ] Others (Specify)

(2) IN CASE OF SICK LEAVE

[ ] In Hospital (Specify)

[ ] Sick
[ ] Out Patient (Specify)

[ ] Maternity
[ ] Others (Specify)

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

[ ] Requested

[ ] Not requested

INCLUSIVE DATES
Signature of Applicant

DETAILS OF APPLICATION
7. (a) CERTIFICATION OF LEAVE CREDITS as of

Vacation

Sick

Total

Days

Days

Days

Personnel Officer
7. (c) APPROVED FOR:

7. (b) RECOMMENDATION

[ ] Approval
[ ] Disapproval due to

7. (d) APPROVED DUE TO:

Days with pay

Days without pay
Days with pay
(Signature)