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Republic of the Philippines

REGION IX
PROVINCE OF ZAMBOANGA DEL SUR
Pagadian City
PROVINCIAL GOVERNOR’S OFFICE
Tel. No. (062) 2141427

-Drivers Trip Ticket-

Date:_ ___________
A) To be filled by the Administrative Official:
Authorizing Official travel:
1) Brand and Variant of Vehicle: _________________________________
2) Plate No. of vehicle used: _________________________________
3) Name of Authorized Passenger/s:
1.
2.
3.
4.
5.
4) Place/Places to be Visited: __________________________________
5) Duration of Travel: From _____________ To _____________
6) Purpose:___________________________________________________________

JEOFE P. SUSON
Provincial Administrator
B) To be filled by the driver
1) Time of Departure from Office/garage: _________________
2) Time of Arrival at (Per no. 4): _________________
3) Time of Departure from (Per no. 4): _________________
4) Time of Arrival back to the office/garage: _________________
5) Approximate distance travelled (to & from): _________________ Miles/kilometres
6) Gasoline issued/purchased and consumed;
a. Balance in Tank _________________ Litres
b. Issued by the Office from stock _________________ Litres
c. Add purchase during trip _________________ Litres
d. Total _________________ Litres
e. Deduct used during trip _________________ Litres
f. Balance in tank _________________ Litres
7) Gear oil used _________________ Litres
8) Lubricant oil issued _________________ Litres
9) Grease issued _________________ Litres
10) Speedometer reading if any;
(i) At the beginning of the trip ____________________ Miles/kilometres
(ii) At the end of the trip ____________________ Miles/kilometres
(iii) Distance travelled (Per Above) ____________________ Miles/kilometres

I hereby certify to the correctness of the above statement of the said travel.

__________________________________
Driver

I hereby certify that I used this car on official business as stated above.
___________________________________
Name of Passenger and Signature