CSC Form 6

Revised 1998

APPLICATION FOR LEAVE

1. Office/Agency 2. Name (Last) (First) (Middle)
APMC / DOH
3. Date of Filing 4. Position 5. Salary

DETAILS OF APPLICATION
6. A) Type of Leave 6. B) Where Leave will be spent:
Vacation 1. In case of Vacation Leave
To seek employment Within the Philippines
Others (Specify) Abroad (Specify)

Sick 2. In case of Sick Leave

x Maternity In hospital (Specify)
Others (Specify)

6. C) Number of Working Days applied for: 6. D) Commutation

Requested Not Requested
Inclusive Dates

Signature of Applicant
DETAILS OF ACTION ON APPLICATION
7. A) Certification of Leave Credits 7. B) Recommendation:
as o

Vacation Sick Total Approval

Disapproval due to
days days days

MERLYN S. LUGO OWAIDA M. MACUD

Supervising Administrative Officer
Authorized Official
7. C) Approved for:
days with pay
days without pay
Supervising Administrative Officer
Authorized Official
7. D) Disapproved due to:

Signature

LUZ A. SABER, MD, MHA, FPSMS

Officer-In-Charge, Medical Center Chief II
Authorized Official
Date: _________________
ested