. Form No.

6
Revised 1994

APPLICATION FOR LEAVE

1. OFFICE/AGENCY 2. NAME (Last) (First) (Middle)

Department of Education

3. DATE OF FILING 4. POSITION 5. SALARY (Monthly)

Employee No:
6. (a) TYPE OF LEAVE 6. (c) WHERE LEAVE WILL BE SPENT IN CASE OF
VACATION LEAVE
[ ] Vacation
[ ] Transact Employment [ ] Within the Philippines
[ ] Others (Specify) [ ] Abroad (Specify)
______________________
[ ] Sick ______________________
[ ] Maternity ______________________
[ ] Others (Specify) 6. (d) COMMUTATION

6. (b) NUMBER OF WORKING DAYS [ ] Requested [ ] Not Requested

APPLIED FOR _____________
Inclusive Dates ________________
________________ ___________________________
(Signature of Applicant)

DETAILS OF ACTION OF APPLICATION

7. (a) CERTIFICATION OF LEAVE 7. (b) RECOMMENDATION
CREDITS as of ___________________
[ ] Approved

[ ] Disapproved due to __________________

Vacation Sick Total __________________

Days Days Days

____________________________
(Authorized Official)
RENZ ROY A. RAMOS, A.O. IV
(Authorized Official)

7. (c) APPROVED FOR 7. (d) DISAPPROVED DUE TO

_________ Days with pay __________________________________________

_________ Days without pay __________________________________________
_________ Others __________________________________________

NATIVIDAD P. BAYUBAY, CESO VI

Schools Division Superintendent
(Authorized Official)

Note:

1. Application for Vacation of Sick Leave for one (1) full day or more shall be in this form.
2. Application for Vacation Leave filed in advance or whenever possible, five (5) days before going on such
leave.
3. Application for Sick Leave filed in advance or exceeding five (5) days shall be accompanied by a medical
certificate with documentary stamp issued by a Government Physician and their License Number should be
clearly indicated.
 Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
Division of ZamboangaSibugay
FIELD OFFICE OF KABASALAN

--------------------

The Schools Division Superintendent

Division of ZamboangaSibugay
Ipil, ZamboangaSibugay

Sir/Madame:

I have the honor to request that my absences ________________________________

(In figure)
___________________________________ Days from _____________ 20____ to ___________
20____ be offset from my vacation service credits.

Enclosed are Civil Service Form # 6 (Application for Leave) and Civil Service Form # 41
(Medical Certificate).

RECOMMENDING APPROVAL:

_____________________________
Principal/Head Teacher

Very truly yours,

______________________________
(Signature over Printed Name)

1stIndorsement
Field Office of Kabasalan

Respectfully forwarded to the Division Superintendent of Schools, Zamboanga

Sibugay, Ipil, Zamboanga Sibugay, recommending approval on the request of
_________________________________ who has earned vacation service credits as per Division
Administrative Order (DAO) no. _______________ series ______________.

___________________________
School Head
 MEDICAL CERTIFICATE

I HEREBY waive my right and privileges pertaining to professional confidence between

physician and patient and the physician accomplishing this form are authorized to answer on
detail all questions contained herein.

________________________
Name of Patient
(N.B) Attending physician should fill in the blank below. Every detail should be answered to avoid
in action application for leave submitted by the patient.

_____________________________ of the DEPARTMENT OF EDUCATION having made application for

leave of absence on account of illness. I do hereby certify that I was the applicant’s attending
physician from __________________ to _________________ inclusive and from my professional
knowledge of the case the following statements are submitted by the provision of Section 7 of
the Civil Service Rule XVL.

Name of the Disease or Disability

_____________________________________________________________________________________________
Nature of the Disease or Disability
_____________________________________________________________________________________________

ETIOLOGY: Under this heading, in addition for giving fully the Etiology of the disease or disability,
the physician must either state in the language of Executive Order. There are no indications
whether that the disease named was due to immoral or vicious habit or give the indication.

_____________________________________________________________________________________________
History:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Description:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

A laboratory test/examination was ______________________ made in this case. The

applicant was confined to his/her house/hospital from ________________________ to
________________________ inclusive.

I HEREBY CERTIFY that the above statement are complete and true in every detail and
that in absence of the disease or disability above specified applicant was ill/unable to be on
duty on account of illness from ______________________ to ___________________inclusive and that
his/her claim is meritorious.

Signature ___________________________
Designation _________________________
Address ____________________________

Date: _____________________________
Documentary Stamp
 Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
Division of ZamboangaSibugay
DISTRICT OF KABASALAN

Date: ______________________

The Schools Division Superintendent

Division of ZamboangaSibugay
Ipil, ZamboangaSibugay

Madam:

I have the honor to apply for reinstatement from ______________ Leave of Absence
effective ______________, 20 ___. I was on _______________ leave for the period from _____________,
20 ____ to ______________, 20 ___. This office on __________________ , 20 ____ approved this leave.
Forms or pertinent papers marked X below are herewith submitted as required.

______________ Original Copy of Birth Certificate of my child

______________ Medical Certificate with documentary stamp duly accomplished by government
physician certifying that I am now fit to return to teach/work
______________ Transcript of Official Record date _________, 20 ___ , is from the study leave of
absence______________ Special Order of Graduation from study leave

The following data are also furnished for the information of the office:

1. My leave was for the period from ________________, 20 ____ to __________________, 20 ____.
2. I delivered on __________________ , 20____.
3. That I extended my leave from __________________, 20____ to ___________________, 20____.
4. Number of days service credits used to be offset this leave was _________.
5. The last balances of my service credits after deductions from the same from this leave will
be _____ days.
6. Name of substitute to be dropped ___________________________________.

Very truly yours,

__________________________________
Signature of teacher/employee

Present Salary per annum ___________

Div. Code: 144 Sta. Code: 006
Employee Number ________________

1stIndorsement
District of Kabasalan

Respectfully forwarded to the Division Superintendent of Schools, Division of

ZamboangaSibugay, Ipil, ZamboangaSibugay, recommending approval of the reinstatement of
Mr/Mrs _____________________________Effective ____________________, 20 ____.

__________________________
District Supervisor
 Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
Division of ZamboangaSibugay
FIELD OFFICE OF KABASALAN

July 19, 2018

NATIVIDAD P. BAYUBAY, CESO VI

Schools Division Superintendent
Division of ZamboangaSibugay
Ipil, ZamboangaSibugay

MADAM:

I have the honor to recommend Ms.Eleonor E. Montecalvo, Provisional

Substitute Teacher vice Mrs. Josephine G. Tayros regular teacher of Lacnapan
Elementary School, this district who is on Sick Leave of Absence effective
July 18, 2018 to August 16, 2018.

Here is some information of the recommended:

Inclusive period of service: July 18 , 2018 to August 16, 2018

School Assignment: Lacnapan Elementary School
Civil Service Eligibility: Licensure Examination for Teachers (LET)
Place Taken: Pagadian City
1. Highest Educational
Attainment: Bachelor in Elementary Education
Year Graduated: 2017
Latest Performance Rating: None
2. Employee No: None
3. Taxpayer’s Identification No: Applied
4. Date of Birth: February 22, 1994
5. Place of Birth : Labuagon, Kibawe, Bukidnon
6. Previous Appointment of the
School Year: None
7. Reasons for recommending
this applicant: Eligible to handle the position.

Very truly yours,

EVANGELINE B. APARICE
SCHOOL HEAD

APPROVED:

NATIVIDAD P. BAYUBAY, CESO VI

Schools Division Superintendent
 Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
Division of ZamboangaSibugay
DISTRICT OF KABASALAN

July 6, 2018

The Schools Division Superintendent

Division of ZamboangaSibugay
Ipil, ZamboangaSibugay

MADAM:

I have the honor to submit herewith the following to wit;

1. Application for Leave of Absence of the following teachers:

a. Francel S. Mangangot
b. Amelinda R. Gumandao
c. Sonia V. Cervantes
d. Josephine P. Natividad
e. Criselda R. Simbol
f. Fernando M. Bucan
2. Monthly Payroll Worksheet and Report of Service for the month of
June 2018.
3. Proportional vacation Pay Computation of Goodyear PS

Please acknowledge receipt hereof.

Very truly yours,

EVELYN A. MANCERA
Principal