· ./.

FORM 6(Revised as of March 2009)

1.0FFICEIDISTRICT 2~LAST NAME: FIRST NAME: M.I.DepEdI

3. DATE OF FILING: 4.PosmON: 15. SALARY:"

6. TYPE OF LEAVE 7. WHERE LE~ VE"WILL BE SPENTVacation In case of Vacation Leave--

_"__ within the Philippines__ To seek employment __ abroad (specify)__ Others (specify)

In case of Sick Leave

-- Sick __ in hospital (specify)__ Maternity __ out-patient (specify) -

No. of working days applied for: Commutation: __ " Requested __ Not Requested

Inclusive days: Printed Name & Signature of Applicant"~"

8. CERTIFICATION OF LEAVE 9. RECOMMENDA TIONfCREDITS IAs of ! "

Appr~val DisapprovalVacation Sick TOTAL i

!!

" i

Days Days Days !i

+--"~- -- ---,- ._.-

EDIT A S. CANO School HeadI

District SupervisorAdministrative Officer V

I10. Approved for: 11. Disapproved due to: I

i__ "__ "days with pay

--_._----

days without pay i -_-_ ..-----_.-days(others, specify) I

! -"------_._.I .._--

DATE: ii

Assistant Schools Division Superintendent

DATE

"SPECIAL ORDERNo. __ , s. 2009

The application for_" __ .day/s __ ~=- ~" leave of absence with/without pay on ~----~-_.,-- _,___ -_,_~~---_PermanentNational Elementary Grades Teacher ofis hereby approved.

of

This established a service credit balance of __ -,- day/s which maybe used to offset future absences due to illness.

By Authority of the DepEd Regional Director:

RAUL D. AGBAN"Assistant Schools Division Superintendent

Copy Furnished:Teacher ConcernedDivision Office FileDistrict Office File