ABCDEFGHIJKLMNOPQRSTUVWXYZ
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Republic of the Philippines
UNIVERSITY OF THE PHILIPPINES
CU : BAGUIO
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APPLICATION FOR U.P.-APPROVED LEAVE
(RA 9500 Sec. 13(k))
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1. OFFICE/DEPARTMENT
2. NAME : (Last) (First) (Middle)
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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 (NON-CUMULATIVE) TO BE AVAILED OF
6.B DETAILS OF LEAVE
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Additional Special Leave (3 days)
In case of Special Leave:
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Sickness Leave (5 days)
Within the Philippines ________________________
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Hospitalization Leave of Immediate Family (2 days)
Abroad (Specify) ___________________________
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Nursing Leave for nursing mother (2 days)
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In case of Sickness Leave:
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Others: CNA SICK LEAVE
In Hospital (Specify Illness) ___________________
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Out Patient (Specify Illness) __________________
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6.C NUMBER OF WORKING DAYS APPLIED FOR ___________________
________________________________
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INCLUSIVE DATES ________________________
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(Signature of Applicant)
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7. DETAILS OF ACTION ON APPLICATION
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7.A CERTIFICATION OF LEAVE BALANCE (Non-Cumulative)
7.B RECOMMENDATION
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as of _______________________For approval
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TypeTotalLess : This ApplicationBalance
For disapproval due to ______________________
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VICTORIA LOURDES C. DIAZ
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Chief, Human Resources Development OfficeDean
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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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Authorized Official
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Date : ________
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