1. OFFICE/ AGENCY

2. NAME (Last) (First) (Middle)

3. DATE

4. POSITION

5. SALARY (Monthly)

DETAIL OF APPLICATION6.(a) TYPE OF LEAVE

[ ] Vacation/ FORCED LEAVE [ ] To seek employment [ ] Others (Specify) (Special) Mourning Leave [ ] Sick [ ] Maternity

6. (b) WHERE LEAVE WILL BE SPENT(1) IN CASE OF VACATION LEAVE

[ ] Within the Philippines[ ] Abroad (specify) ____________________

6. (2) IN CASE OF SICK LEAVE

[ ] in hospital (specify) ___________________ _____________________________________[ ] out patient (specify) ___________________ _____________________________________

6. (c) NUMBER OF WORKING DAYS APPLIED FOR:

INCLUSIVE DATES

____________________________

____________________________ ____________________________ ____________________________

COMMUTATION

[ ] Requested [ ] Not requested

______________________(Signature of Applicant)

DETAILS OF ACTION ON APPLICATION

7. (a) CERTIFICATION OF LEAVE CREDITS

as of ___________________________

7. (b) RECOMMENDATION

[ ] Approved [ ] Disapproved due to ___________________ _________________________________________ _________________________________________

_____________________Principal 1

Vacation Sick Total

______________________Administrative Officer

7. (c) APPROVED FOR: 7. (d) DISAPPROVED DUE TO: __________ Days with pay ______________________ __________ Days with out pay ______________________ __________ Others (specify) ______________________

________________

Signature_______________________

Administrative Officer DesignateDate: ____________