DOJ FORM NO.

___

APPLICATION FOR WELLNESS LEAVE

1. OFFICE 2. NAME: Last Name: First

OPP - CABAGAN GONZAGA JOHANS

3. Date of Filing: 4. Position
MAY 17, 2018 PROSECUTOR I

DETAILS OF APPLICATION

6. A) Type of Leave 6. B) Where leave will be spent:

Within the Philippines

WELLNESS BENEFITS LEAVE Abroad (Specify)
__________________________________
C) Number of Working Days applied for:
_______________________________

Inclusive Dates:
_______________________________ __________________________
_______________________________ Signature of Appplicant

DETAILS OF ACTION ON APPLICATION

7. A) Certificate of Wellness Leave Credits: 8. B) Recommendation:

Date: _______________________
Total: ______________________

CERTIFICATION
I hereby certify that no public service shall be
disrupted by reason of the leave of absence of
the applicant.
________________________________
Authorized Officer (Head of Office)

8. A) Approved for: 8. B) Disapproved due to:

__________days _________________________
 _________________________

__________________________________________
(Signature Over Printed Name)
Authorized Official

__________________________________________
Date
LEAVE

Middle

S.
5. Salary

e will be spent:

Within the Philippines

Abroad (Specify)
_________________________________

_________________________
ignature of Appplicant

ATION

ommendation:
Approval
Disapproval due to:
__________________
CERTIFICATION
hat no public service shall be
son of the leave of absence of

(Head of Office)

approved due to:

________________________
________________________