(Revised 1995) Form 6
DEPARTMENT OF EDUCATION
Region V
DIVISION OF SORSOGON
Sorsogon
APPLICATION FORM
1. OFFICE /AGENCY 2. NAME (LAST) (FIRST) (MIDDLE)
DEPARTMENT OF EDUCATION________ELEP___ EDWIN____________ M. _____
3. DATE OF FILLING 4. POSITION 5. SALARY
___03/06/2020_____________________________ HT- II_______________________32, 431.00_______
DETAILS OF APPLICATION
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. (a) TYPE OF LEAVE (b) WHERE LEAVE WILL BE SPEND
(1) _____Vacation (1) In case of vacation leave
_____To seek employment ____ Within the Philippines
_____Others (Specify ) ____ Others ( Specify )
_______________________________________________________________________________________________
(2) ____ Sick Leave (2) In case of Sick Leave
____ Maternity Leave Name of Hospital ___________________
___ Others (Specify) _______________ Others (Specify) ____________________
______30 days monetization_________ ( at home, etc. )
6. (c) NUMBER OF WORKING DAYS
Applied for: ____ ____ COMMUTATION:
From: _ ____ _______ Requested ________ Not Requested
_______________________________
Signature of Applicant
DETAILS OF ACTION OF APPLICATION
7. (a) CERTIFICATION OF LEAVE CREDITS 7. (b) RECOMMENDATION
AS OF _______________________________
___________________________________ _________________________ APPROVED
Vacation : Sick : Total : _________________________ DISAPPROVED DUE TO
_________________________________________________________________________________________________________________________________________________________________________________________
: :
_________________________________________________________________________________________________________________________________________________________________________________________
: _______________________________________________
LESS: This Leave
_________________________________________________________________________________________________________________________________________________________________________________________
: :
________________________________________________________________________________________________________________________________________________________________________________________
:
Balance :
________________________________________________________________________________________________________________________________________________________________________________________
____________:____________:_________:
____________ __________
( Authorized Signature )
____________________________________
JOMAR E. ENGUERRA _ _________________
Administrative Aid VI ( Designation )
OIC-Office of the HRMO
7. (c) APPROVED FOR : 7. (d) DISAPPROVED DUE TO :
__________________ Days with full pay ____________________________________________
__________________ Days without pay ____________________________________________
__________________ Others ( specify )
________________________________________________
JOSE L. DONCILLO, CESO V
Schools Division Superintendent
Republic of the Philippines
Department of Education
DIVISION OF SORSOGON
REGION V
Sorsogon
Date : _____________________
DIVISION SPECIAL ORDER
No. ______ S, ______ 20___
The return to duty from Sick Leave / Vacation / Maternity Leave of absence of the hereunder
listed National ( Municipal ) Elementary Grades Teacher is hereby made a matter of record :
1. Name : _______________________________________
2. Employee Number : _____________________________
3. Municipality : Donsol East District , Donsol_________
4. Civil Service Status : Regular / Permanent____________
5. Monthly SALARY : ______________________________
6. Division Item Number : ___________________________
7. Inclusive Dates of : ______________________________
8. From : _________________ To : ___________________
9. Date of Return to Duty : __________________________
Recommended by :
ADAM A. SY
ESHT – I
APPROVED :
DR. LOIDA N. NIDEA, Ed. D. CESO V
Schools Division Superintendent
Copy Furnished :
The Teacher Concerned
The Director of Public Schools, Manila
Supervisor, Accounting Machine Section, Manila
Division Office
Republic of the Philippines
Department of Education
DIVISION OF SORSOGON
REGION V
Sorsogon
___________________________
Date
The Chief
Accounting Machine Division
IBM Budget Commission
U.L. Complex , Pasig City
The application for leave of absence on the C.S. Form 6 of __________________________________
is hereby approved in accordance with Executive Order No. 234 dates February 11, 1941 , as follows;
Pertinent Data :
1. Employee Number : __________________________________________
2. Municipality : Donsol _________
3. Service Rendered : _____________ ____________
4. Absence : __________________________________________________
5. Experience as : ___________________ from _______________________
6. Monthly Salary : _____________________________________________
7. Item Number : ____________________ Page _____________________
8. Division Office Plantilla : ______________________________________
By Authority of the Secretary of Education
DR. LOIDA N. NIDEA, Ed. D. CESO V
Schools Division Superintendent
Recommended by :
ADAM A. SY
ESHT – I
CSC FORM 41
MEDICAL CERTIFICATE
I hereby waive all rights and privileges pertaining to professional confidence between
physician and patient and the physician accomplishing this form is authorized to answer in detail all
questions contained therein .
_________________________________
Signature of Patient
Attending physician should fill the blanks below . Every detail should be answer to avoid
delay in application for leave submitted by the patient .
___________________________________ of DepEd, Division of Sorsogon, having made
application for leave of absence on account of illness. I do hereby certify that I was that I was the
applicant`s attending physician from ______________________ to ______________________
inclusive and from professional knowledge of the case the following statements submitted as
contemplated by the provision of Section 8 C.S.C. Rule XVI.
Nature of disease or disability : _________________________________________________
Nature of disease or disability : _________________________________________________
ETIOLOGY : Under this heading, in addition to giving fully the etiology of the disease or disability,
the physician must state in language of the executive order: “There is no indications whatever that the
disease named were due to immoral or vicious habits”
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
HISTORY :
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
A laboratory test or examination was _____________________________________ made in
this case. The application was confined to ______________________________________or his/her
house from _______________________ to_______________________ inclusive.
I hereby certify that the above statements are complete and true in every detail, and that in
consequences of the disease or disability above specified application was ill and unable to be on duty
on account of illness from _________________________ to _________________________
inclusive, and that his/her claim is meritorious.
_________________________________
Medical Officer
___________________________
Date
CSC Form No. 6
Revised 1984
