CSC Form No.

6
(Revised as of March 2008 for Non-Teaching)

1. Office Agency: 2. Name: (Last) (First) (MI)

DepEd -
3. Date of Filing: 4. Position: 5. Salary (Monthly)

6. Type of Leave: 7. Where Leave will be spent:

Vacation In case of Vacation Leave

To seek employment Within the Philippines
Sick Abroad (Specify)
Maternity
Others (Specify) In case of Sick Leave
In Hospital (Specify)

Out Patient (Specify)

Number of Working Days Applied for: Commutation:

Inclusive Dates : Requested Not Requested

Printed Name & Signature of Applicant

8. CERTIFICATION OF LEAVE CREDITS 9. Recommendations:

as of
Approval
Vacation Sick Total
Disapproval

School Head

EDITA S. CANO
Administrative Officer V Public Schools District Supervisor

10. Approved for: 11. Disapproved due to:

days with pay
days without pay
others (specify)

Date:

JOEL A. ZARTIGA, Ph. D.

Officer In-Charge
Assistant Schools Division Superintendent

SPECIAL ORDER Date

No. ___________, s. 20____

The application for leave of absence with/without pay for the period ___________________________________________ of
Mr./Mrs./Ms. ____________________________________________, ___________________________________ of Calbayog City
Name Designation
Division is hereby approved/disapproved in accordance with Executive Order No. 284 dated January 19, 1971. Same are being offset to
his/her credits.

By Authority of the DepEd Regional Director:

Copy Furnished:
Concerned
Division Office File JOEL A. ZARTIGA, Ph. D.
Office File Officer In-Charge
Assistant Schools Division Superintendent