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Civil Service Form No. 6
ANNEX A
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Revised 2020
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DEPARTMENT OF EDUCATION
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Region III
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 Division of Mabalacat City
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Mabalacat City, Pampanga
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Tel.No.: (045) 331-8143/Email Add: mabalacat.city@deped.gov.ph
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APPLICATION FOR LEAVE
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1. OFFICE/DEPARTMENT
2. NAME:(Last)(First)(Middle)
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MABALACAT ELEMENTARY SCHOOL
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3. DATE OF FILING
4. POSITION 5. SALARY
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6. DETAILS OF APPLICATION
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6.A TYPE OF LEAVE TO BE AVAILED OF
6.B DETAILS OF LEAVE
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Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
In case of Vacation/Special Privilege Leave:
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Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Within the Philippines
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Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Abroad (Specify)
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Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS)
In case of Sick Leave:
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Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended)
In Hospital (Specify Illness)
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Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Out Patient (Specify Illness)
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Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004)
In case of Special Leave Benefits for Women:
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Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
(Specify Illness)
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10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005)
In case of Study Leave:
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Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Completion of Master's Degree
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Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010)
BAR/Board Examination Review Other
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Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended)
purpose:
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Adoption Leave (R.A. No. 8552)
Monetization of Leave Credits
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Others:Terminal Leave
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6.C NUMBER OF WORKING DAYS APPLIED FOR
6.D COMMUTATION
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Not Requested
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INCLUSIVE DATES
Requested
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(Signature of Applicant) Employee No.
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7. DETAILS OF ACTION ON APPLICATION
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7.A CERTIFICATION OF LEAVE CREDITS
7.B RECOMMENDATION
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As of
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Vacation LeaveSick LeavexFor approval
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Total Earned
For disapproval due to
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Less this application
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Balance - -
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JENNIFER G. SOTTORIAH A. YUTUC, EdD
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Administrative Officer IVPrincipal III
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7.C APPROVED FOR:
7. D DISAPPROVED DUE TO:
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days with pay
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days without pay
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others (Specify)
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ARMANDO C. CAPILI, EdD
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Assistant Schools Division Superintendent
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