CSC Form No.

_______
Revised 1984

APPLICATION FOR LEAVE

1. OFFICE/AGENCY 2. a) NAME 2. b) EMPLOYEE NO.
(Last) (First) (Middle)

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

M M D D Y Y Y Y

DETAILS OF APPLICATION
6. a) TYPE OF LEAVE 6. b) WHERE LEAVE WILL BE SPENT
1. IN CASE OF VACATION LEAVE
Vacation
To seek employment Within the Philippines
Others, specify: _______________ Abroad (specify) ____________________
Sick
Maternity 2. IN CASE OF SICK LEAVE
Others, specify: __________________ __ In Hospital (Specify) _________________
Special Privilege Out Patient (Specify)___ ________
Birthday Relocation
Filial Hospitalization 6. d) COMMUTATION
Anniversary Mourning Requested
Enrollment Funeral Not Requested
Graduation Gov’t Transaction
6. c) NUMBER OF WORKING DAYS
APPLIED FOR ______
INCLUSIVE DATES:
_____________________
(Signature of Applicant)
DETAILS OF ACTION ON APPLICATION
7. a) CERTIFICATION OF LEAVE CREDITS 7. b) RECOMMENDATION
As of ______________________ Approved
Disapproved due to ____________________
VACATION SICK TOTAL ____________________________________

______________________________ _________________
Personnel Officer Authorized Official
7. c) APPROVED FOR: 7. d) DISAPPROVED DUE TO:

days with pay

days without pay
others (specify)

________________________
Authorized Official