Diliman, Quezon City,

Multi-dimensional Imaging Center 1101 Philippines

(MDIC)
Phone no: (632) 9247392 (CS);
Technology Incubation Core Facility (632) 926-1002 (NIP)
(TICF) Fax no: (632) 9247674 (CS)

National Science Complex, College of

TICF FORM 3
Statement of Charges

Reference No: _____

Date: October 6, 2009

Name of Requesting Party: ____________________________________
Name of User: _________________________________

The following amount will be billed to you for the services rendered by the
Technology Incubation Center of the National Science Complex:

PARTICULARS RATE (cost per QUANTITY (in terms of SUBTOTAL

hour or per hours, no. of samples, etc)
sample, etc)

a. Use of Equipment:

b. Analytical and testing

services:

c. Methods development
and optimization:

d. Consultancy services:

e. Other charges:
(professional fee, etc.)

Total Amount to be paid by the client:

Please pay at the University of the Philippines, Diliman Cashiers’ Office for
deposit to College of Science Trust Account No. 9774192-499-439.

Approved by: Prepared by:

___________________________ __________________________
Florentino C. Sumera, PhD
MDIC Coordinator/ Professor, UP-MSEP