Civil Service Form No.
6
Revised 2020
Department of Education
Region I Stamp of Date of Receipt
SCHOOLS DIVISION OFFICE I PANGASINAN
DIVISION SUB- OFFICE ANDA DISTRICT
EMPLOYEE #: 4219415
APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
DEPED- ANDA IS
DOMALANTA CATHERINE JOY CAROLINO
May 26,2022 TEACHER II P 27, 608.00
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
PERSONAL LEAVE
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION
1 DAY
________________________________________ Not Requested
INCLUSIVE DATES Requested
May 26, 2022
________________________________________
(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 ___________________________________________
NELIA C. SANTOS CARLA FATIMA D. SORIANO
___________________________________________
(Authorized Officer) (Authorized Officer)
Administrative Officer IV, Personnel PRINCIPAL II
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
MA. CRISELDA G. OCANG, CESE
Assistant Schools Division Superintendent
_________________________________
(Authorized Official)
Civil Service Form No. 6
Revised 2020
Department of Education
Region I Stamp of Date of Receipt
SCHOOLS DIVISION OFFICE I PANGASINAN
DIVISION SUB- OFFICE ANDA DISTRICT
EMPLOYEE #: 4105083 APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
DEPED- MAL-ONG ES CASPE PEDRO ONG
NOVEMBER 24,2021 TEACHER I P 23, 837.00
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
SICK LEAVE
SICK LEAVE
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION
30 DAYS
________________________________________ 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 ___________________________________________
SCHOOL HEAD NAME
NELIA C. SANTOS ___________________________________________
(Authorized Officer) (Authorized Officer)
Administrative Officer IV, Personnel PRINCIPAL
MA. CRISELDA G. OCANG, CESE
Assistant Schools Division Superintendent
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
ELY S. UBALDO, CESO VI
Assistant Schools Division Superintendent
Officer-In-Charge Office of the Schools Division Superintendent
_________________________________
(Authorized Official)
