Department of Education
Region V
Division of Camarines Sur
DEL GALLEGO DISTRICT
Nov.22,2018
Date
The Schools Division Superintendent
Division of Camarines Sur
Freedom Sports Complex
San Jose,PiliCamarines Sur
(Thru Channels)
MADAM:
I have the honor to apply for Two ________( 2 ) ______ Working Days
Sick/Maternity/Personal/Vacation leave of absence with/without pay from
November 22,2018 to_November 23,2018.
I further request that my leave of absence be offset by the following duly earned service credits,
to wit;
Attached herewith is /are my Form 6, Form 48, Certificate.
____________________________________________________________________________________
Very truly yours,
MA. LEAH R. SUARILLA
Position: Teacher - I
Employee No.4820472
Approved:
MARCELA R. COLLANTES
Head Teacher 1
Department of Education
Region V
Division of Camarines Sur
DEL GALLEGO DISTRICT
PAPERS FOR
REINSTATEMENT
CAMILLE GREY I. RAZONA
Position: Teacher - I
Employee No.4820603
Department of Education
Region V
Division of Camarines Sur
DEL GALLEGO DISTRICT
November 26,2018
Date
The Schools Division Superintendent
Division of Camarines Sur
Freedom Sports Complex
San Jose,PiliCamarines Sur
(Thru Channels)
MAdam:
I have the honor to apply for reinstatement to service effective November 26,2018
I was on Sick/Maternity/Personal/Vacation leave of absence from
November 22,2018 to_November 23,2018.
Attached herewith is /are my Form 6, Form 48, and memo.
________________________________________________.
Very truly yours,
MA. LEAH R. SUARILLA
Position: Teacher - I
Employee No.4820472
Approved:
MARCELA R. COLLANTES
Head Teacher 1
Form 6
1. OFFICE/AGENCY 2. (Last Name) ( First Name) (Middle Name)
Department of Education_ SUARILLA MA. LEAH REFE
3. DATE OF FILLING 4. POSITION 5. MONTHLY
____November 22,2018______________ ____Teacher-1_________________P 20,179.00
DETAILS OF APPLICATION
6. (a) TYPE OF LEAVE 6. (b) WHERE LEAVE WILL BE SPENT
Vacation (1) IN CASE OF VACATION LEAVE
To seek employment Within the Philippines
Others (specify) ______________
_____________________ Abroad(Specify)
Sick (2.) IN CASE OF SICK LEAVE
Maternity In Hospital
Others (specify) _____________________ Out Patient (Specify)
____________________ _______________________
6. (c) NUMBER OF WORKING DAYS 6. (d) COMMUTATION
APPLIED FOR _______ ___ Requested Not Requested
INCLUSIVE DATES: __________________
_________________________________
________________________________
Signature of Applicant
Employee No.4820472
DETAILS OF ACTION ON APPLICATION
7. (a) CERTIFICATION OF LEAVE CREDITS 7. (b) RECOMMENDATION
As of ____________________________ APPROVED
Vacation Sick Total DISAPPROVED DUE TO
_________________________
____________________________ MARCELA R. COLLANTES
(Personnel Officer) Head Teacher-1
7. (c) APPROVED:
_____________ Days with pay
_____________ days without pay
______________ other( specify) DOLORES Q. MAPUSAO
(Authorized official)
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INSTRUCTIONS
Applicant for vacation or sick leave for one full dayor more shall made on this form and accomplished at least in duplicate.
Application for vacation leave shall be filed in advance or whenever possible five (5) shall be accompanied by medical
certificate. In caseof Medicalconsultationwas not availed of an affidavit should be executed by applicant.
An employee who is absent without approved leave shall not be entitled to received her/his salary corresponding to the
period of his/her unauthorized leave of absence.
An applicant for leave of absence for thirty (30) calendar days or more shall accompanied by clearance for money and property
responsibilities
C.S.C Form 41
PHILIPPINE CIVIL SERVICE
MEDICAL CERTIFICATE
I HEREBY WAIVE all rights and privileges pertaining to professional confidence between
physician and patient, and the physician accomplishing this form as authorized to answer in
detail all questions contained herein
_____________________________
Signature of the Patient
(F.B) Attending physician should fill in the blanks below. Every detail should answer to avoid
delay in action on application for leave submitted by the patient.
__________________________________ of the Bureau of Public schools having made
application forleave of absence on account of illness. I HEREBY CERTIFY, that I was the
applicant’s attending physician from ____________________ to ___________________,2019,
inclusive and from professional knowledge of the same of the following statement are
submitted as contemplated by provision of section B of civil service Rules VI.
Name of the diseases of disability
________________________________________________________
______________________________________________________________________________
____
______________________________________________________________________________
____
Biology. Under this having in addition to giving fully the sociology of the disease or disability,
the physician must either state on the language of the executive order there are no indication
whatsoever that the disease was name was due to immoral or vicious habits or give indications.
____________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________.
A laboratory test or examination was made in this case.
The applicant wasconfined to the house, hospitalized from _________201__to
_________201__
Inclusive
I HEREBY certify that the above statement are complete and true in every detail in that
consequences of the disease or the disability above, specified the applicant was ill and un able to
be or duty on account of illness from______________________,201__ to __________________
201_____Inclusive in that this claim is meritorious.
Affix (Signature) ___________________
Documentary (Printed) ____________________
Stamp (Public Address) _______________
Date: _________________________ ____________________________
Department of Education
Region V
Division of Camarines Sur
DEL GALLEGO DISTRICT
_______________________
Date
KINALANGAN ELEMENTARY SCHOOL
Name of School
CERTIFICATION
TO WHOM IT MAY CONCERN
This is to certify____________________________________, _____________________
Of this school and/ or district has been cleared of all money and property responsibility in this
school/district as of today______________________________, thus (X) COMPLETE
CLEARANCE in this school/district is hereby granted. Consequently, turnover of property and
Responsibility has been accordingly made to his /her successor in the services.(In case of Head
Of school/District Supervisor/Chief cluster Principal, an invoice Receipt for property turnover
is required ,However , the above mentioned person has completely accounted for all
Governmentproperty received by him/her during his/her tenure of service in this school/district.
MARISSA S. BELGICA GREGORIO S. FRANCISCO, JR.
School Property Custodian School Head/TIC
SHIELA RONQUILLO MARISOL G. QUARIO
District property Custodian Public School District Supervisor
a. Latest and complete permanent Address ______________________________________
b. Amount paid for property losses to school Head/ School/District property Custodian/chief
Cluster Principal _________________________________________
c. Due of payments _________________________________________
d. Purpose of Clearance _________________________________________
(Retirement/transfer/Resignation,etc.)
e. Other Information:
Transfer to what school ___________________________________
Address ___________________________________
Others matters settled, etc. ____________________________________
___________________________________________
Name and Signature of Person Seeking Clearance
CS FORM 211
MEDICAL CERTIFICATE
For employment
PHILIPPINE SERVICECOMMISION
I N S T R UC T I O N S
1. This medical certificate should be accomplished by a government physician.
2. Attached this certificate to original appointments and reinstatements.
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NAME ( Last, First, Middle if married woman :AGENCY:
give her maiden name) :__________________________________
_______________________________________ :__________________________________
=====================================================================
ADDRESS: _______________________________ : PROPOSED POSITION:
_________________________________________: ________________________
AGE: ____ SEX: ____CIVIL STATUS: __________
______________________________________________________________________________
FOR THE PHYSICIAN
I HEREBY CERTIFY that I personally examined the : AFFIX
Above named individual and found him/her to be physically and :DOCUMENTARY
Medically fit/unfit for employment. : STAMP
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SIGNATURE OF PHYSICIAN : CERTIFICATE NUMBER : OTHER INFORMATION
: : ABOUT THE APPOINTEE
: :
OFFICIAL DESIGNATION : HEIGHT( Barefoot) :WEIGHT(Stripped)
: :
: :
AGENCY: : DATE EXAMINED : X-RAY or BUROSCOPY
: : RESULT (only when the
: : physician believes
necessary)
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