Application For Leave
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1CSC 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
Vacation
1. IN CASE OF VACATION LEAVE
Others (specify)______________________
Within the Philippines
___________________________________
Abroad (specify) ____________________
Sick
Maternity
2. IN CASE OF SICK LEAVE
Paternity
In Hospital (Specify) _________________
Out Patient (Specify) _________________
6. c) NUMBER OF WORKING DAYS
6. d) COMMUTATION
APPLIED FOR ____________________
Requested
INCLUSIVE DATES:
Not Requested
FROM
TO
MM DD YYYY MM
DD YYYY
______________________________
Signature of Applicant
DETAILS OF ACTION ON APPLICATION
7. a) CERTIFICATION OF LEAVE
7
. b) RECOMMENDATION
As of ______________________
Approved
Disapproved due to ____________________
VACATION
SICK
TOTAL
____________________________________
______________________________
______________________________
Authorized Official
Personnel Officer
7. c) APPROVED FOR:
7. d) DISAPPROVED DUE TO:
days with pay
days without pay
others (specify)
_________________________________
Authorized Official
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