Civil Service Form No.
6
Revised 2020
Republic of the Philippines
DEPARTMENT OF EDUCATION Stamp of Date of Receipt
SCHOOLS DIVISION OFFICE OF SANTA ROSA CITY
2nd Flr. Leon Arcillas Bldg. Brgy. Market Area, City of Santa Rosa, Laguna
APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
STAMANAHIS POBLACION WILLIE, JR. MONTES
3. DATE OF FILING ______________
1-09-2023 TEACHER II
4. POSITION _____________________________ 27, 608.00
5. SALARY ______________
6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE
Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines _________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) ___________________________
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) ____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ___________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) FEVER
_____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION
1
________________________________________ Not Requested
INCLUSIVE DATES Requested
January 09, 2023
________________________________________
(Signature of Applicant)
7. DETAILS OF ACTION ON APPLICATION
7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________
ROMMEL F. MALLORCA
Principal I
___________________________________________
(Authorized Officer) (Authorized Officer)
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
MABEL F. MUSA, CESE
_________________________________
ASSISTANT SCHOOLS DIVISION SUPERINTENDENT
Civil Service Form No. 6
Revised 2020
Republic of the Philippines
DEPARTMENT OF EDUCATION Stamp of Date of Receipt
SCHOOLS DIVISION OFFICE OF SANTA ROSA CITY
2nd Flr. Leon Arcillas Bldg. Brgy. Market Area, City of Santa Rosa, Laguna
APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY ______________
6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE
Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines _________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) _____________________________
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) ____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ___________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) _____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION
________________________________________ Not Requested
INCLUSIVE DATES Requested
________________________________________
(Signature of Applicant)
7. DETAILS OF ACTION ON APPLICATION
7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________
___________________________________________
(Authorized Officer) (Authorized Officer)
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
MANUELA
MANUELA S. S. TOLENTINO,
TOLENTINO, CESO
CESO V V
_________________________________
SCHOOLS DIVISION SUPERINTENDENT
