Republic of the Philippines

DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (ELEMENTARY SCHOOL)
One (1) Day to Twenty-Nine (29) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3. Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for_____________ r requested not requested
Inclusive dates _______________
_________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
School Head PSDS (in-charge in the area)
Authorized Official Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (JUNIOR HIGH SCHOOL)
One (1) Day to Twenty-Nine (29) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3. Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for_____________ r requested not requested
Inclusive dates _______________
_________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
School Head PSDS (in-charge in the area)
Authorized Official Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (SENIOR HIGH SCHOOL)
One (1) Day to Twenty-Nine (29) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3. Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for_____________ r requested not requested
Inclusive dates _______________
_________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to __________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
School Head PSDS (in-charge in the area)
Authorized Official Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (ELEMENTARY)
Thirty (30) Days to Fifty-Nine (59) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to_____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
PSDS (in-charge in the area) MARILU N. CARDENAS, Ed.D.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (JUNIOR HIGH SCHOOL)
Thirty (30) Days to Fifty-Nine (59) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to_____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
PSDS (in-charge in the area) TEODORA V. NABOR, D.A.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (SENIOR HIGH SCHOOL)
Thirty (30) Days to Fifty-Nine (59) Days
CSC form 6 Revised 1984_____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________________
Disapproved due to_____________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ _________________________________
PSDS (in-charge in the area) TEODORA V. NABOR, D.A.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (ELEMENTARY)
Sixty (60) Days UP
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
_____________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
_____________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ SHEILA MARIE A. PRIMICIAS,CESO VI

PSDS (in-charge in the area) Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the
accomplish at least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days
before going on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be
accompanied by a medical certificate in case medical consultation was nit availed an
affidavit should be filled by the applicant.
4. An employee who is absent without approves leave shall not be entitled to receive
his/her salary corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be
accompanied by a clearance from money and property accountabilities and for
endorsement addressed and duly approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (JUNIOR HIGH SCHOOL)
Sixty (60) Days UP
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
_____________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
_____________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ SHEILA MARIE A. PRIMICIAS,CESO VI

PSDS (in-charge in the area) Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the
accomplish at least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days
before going on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be
accompanied by a medical certificate in case medical consultation was nit availed an
affidavit should be filled by the applicant.
4. An employee who is absent without approves leave shall not be entitled to receive
his/her salary corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be
accompanied by a clearance from money and property accountabilities and for
endorsement addressed and duly approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Teaching and Non-Teaching Personnel (SENIOR HIGH SCHOOL)
Sixty (60) Days UP
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
_____________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
_____________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

____________________________________________ SHEILA MARIE A. PRIMICIAS,CESO VI

PSDS (in-charge in the area) Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the
accomplish at least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days
before going on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be
accompanied by a medical certificate in case medical consultation was nit availed an
affidavit should be filled by the applicant.
4. An employee who is absent without approves leave shall not be entitled to receive
his/her salary corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be
accompanied by a clearance from money and property accountabilities and for
endorsement addressed and duly approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (ELEMENTARY)
One (1) to Fifty-Nine (59) Days
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)

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

__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval __________________
Disapproved due to___________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to __________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

_________________________________ ________________________________________
PSDS (in-charge in the area) MARILU N. CARDENAS, Ed.D.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (JUNIOR HIGH SCHOOL)
One (1) to Fifty-Nine (59) Days
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)

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

__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval __________________
Disapproved due to___________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to __________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

_________________________________ ________________________________________
PSDS (in-charge in the area) TEODORA V. NABOR, D.A.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (SENIOR HIGH SCHOOL)
One (1) to Fifty-Nine (59) Days
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)

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

__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ____________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval __________________
Disapproved due to___________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to __________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

_________________________________ ________________________________________
PSDS (in-charge in the area) TEODORA V. NABOR, D.A.
Authorized Official Assistant Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (ELEMENTARY)
Sixty (60) days to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
_____________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to___________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others

Recommending Approval: Approved:

MARILU N. CARDENAS, Ed.D. SHEILA MARIE A. PRIMICIAS,CESO VI

Asst. Schools Division Superintendent Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
_____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (JUNIOR HIGH SCHOOL)
Sixty (60) days to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
_____________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to___________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to ________
_____________________days with pay
_____________________days without pay
_____________________others

Recommending Approval: Approved:

TEODORA V. NABOR, D.A. SHEILA MARIE A. PRIMICIAS,CESO VI

Asst. Schools Division Superintendent Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
_____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

School Heads (SENIOR HIGH SCHOOL)
Sixty (60) days to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
_____________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
________________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to___________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others

Recommending Approval: Approved:

TEODORA V. NABOR, D.A. SHEILA MARIE A. PRIMICIAS,CESO VI

Asst. Schools Division Superintendent Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
_____________________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Non-Teaching Personnel (Division Office)
One (1) to Fifty-Nine (59) Days
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) _____________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for ______ day requested not requested
Inclusive dates _________________
________________________
Signature of Applicant
_____________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval __________________
Disapproved due to__________
Vacation Sick Total

Days Days Days

_____________________________________________________________________________________
c) Approved for d) Disapproved due to ________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

________________________________ SHEILA MARIE A. PRIMICIAS,CESO VI

Unit Heads Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
_____________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Non-Teaching Personnel (OSDS)
Sixty (60) to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
_______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

RAFAEL IRWIN G. NICOLAS, Ed.D. SHEILA MARIE A. PRIMICIAS,CESO VI

Administrative Officer V Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Non-Teaching Personnel (CID)
Sixty (60) to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
_______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

CARMINA C. GUTIERREZ, Ed.D. SHEILA MARIE A. PRIMICIAS,CESO VI

Chief of CID Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

Non-Teaching Personnel (SGOD)
Sixty (60) to One (1) year
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
______________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
___________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) ___________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) ________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
_______________________
Signature of Applicant
______________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval _______________
Disapproved due to__________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to _________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

ANGELINE S. CASIPIT, Ed.D. SHEILA MARIE A. PRIMICIAS,CESO VI

Chief of SGOD Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the accomplish at
least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days before going
on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be accompanied by a
medical certificate in case medical consultation was nit availed an affidavit should be filled by the
applicant.
4. An employee who is absent without approves leave shall not be entitled to receive his/her salary
corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be accompanied by
a clearance from money and property accountabilities and for endorsement addressed and duly
approved by the Regional Office.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St.Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS); (075) 632-8385(ASDS)
E-mail :pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com

APPLICATION FOR LEAVE

MONETIZATION
CSC form 6 Revised 1984____________________________________________________
1. Office Agency 2. Name (Last) (First) (M.I)
_____________________________________________________________________________
3.Date of Filing 4. Position 5. Salary (Monthly)
__________________________________________________________________________
6. a) Type of Leave (b) Where leave will be spent
Vacation (1) In case of vacation leave
Others (Specify) ______________ within the Philippines
Abroad (Specify) __________
______________________________________________________________________________
Sick (2) In case of Sick Leave
Maternity in Hospital (Specify) _________
Others (Specify) ______________ Out Patient (Specify) _________

c) Number of working days (d) Commutation

applied for________________ requested not requested
Inclusive dates _______________
_______________________
Signature of Applicant
_____________________________________________________________________________
7. a) Certification of Leave Credits b) Recommendation
as of ______________________ Approval ___________________
Disapproved due to__________
Vacation Sick Total

Days Days Days

____________________________________________________________________________________
c) Approved for d) Disapproved due to ________
_____________________days with pay
_____________________days without pay
_____________________others
Recommending Approval: Approved:

RAFAEL IRWIN G. NICOLAS, Ed.D. SHEILA MARIE A. PRIMICIAS,CESO VI

Administrative Officer V Assistant Schools Division Superintendent
Authorized Official OIC-Office of the Schools Division Superintendent
Authorized Official
______________________________________________________________________________
INSTRUCTION
1. Application for vacation or sick for one (1) full day or more shall be made on the
accomplish at least in triplicate.
2. Application for vacation leave shall be in advance or whenever possible five (5) days
before going on such leave.
3. Application for sick leaved filed in advance or succeeding five (5) days shall be
accompanied by a medical certificate in case medical consultation was nit availed an
affidavit should be filled by the applicant.
4. An employee who is absent without approves leave shall not be entitled to receive
his/her salary corresponding to the period of his unauthorized leave of absence.
5. An application for leave of absence for thirty (30) calendar days or more shall be
accompanied by a clearance from money and property accountabilities and for
endorsement addressed and duly approved by the Regional Office.