APR Form Revised March 2007

NAME AND ADDRESS IPIL HEIGHTS ELEMENTARY SCHOOL AGENCY

OF REQUESTING Ipil Heights, Ipil, Zamboanga Sibugay ACCT. CODE
AGENCY Department of Education AGENCY CONTROL No.
TEL. NOS. 062-333-2338
PS APR No.
AGENCY PROCUREMENT REQUEST

To: THE PROCUREMENT SERVICE

Department of Budget and Management (Date Prepared)
Zamboanga City Depot

PLEASE CHECK (⁄) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM/S LISTED BELOW

[ ] Please issue common-use supplies/materials per Price List No. _____________________________ dated________________________
Mode of delivery: [ ] Pick-up (Fast Lane) [ ] Pick-up (Schedule) [ ] Delivery (door-to-door)

In case fund is not sufficient: [ ] Reduce Quantity [ ] Bill Us [ ] Charge to Unutilized Deposit, APR No. _______________ Date _________

[ ] Please purchase for our agency non-common items. Attached herewith:

[ ] Complete Specifications [ ] Obligation Request (ObR) [ ] Others, pls. specify_____________
[ ] Certificate of Budget Allocation (CBA) [ ] Payment _____________________________

IMPORTANT!! PLEASE SEE THE INSTRUCTIONS/CONDITIONS AT THE BACK HEREOF

ITEM No. ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK No. QUANTITY Unit Unit Price AMOUNT
Printer 2 unit ₱7,500.00 ₱15,000.00
Bondpaper 120 reams ₱250.00 ₱30,000.00
Printer ink 8 sets ₱1,200.00 ₱9,600.00
WIFI Modem 9 pcs ₱1,577.89 ₱14,201.01
Monthly bill (Electric) 1 monthly ₱4,144.97 ₱4,062.13
Monthly bill (Electric) 1 monthly ₱5,576.75 ₱5,576.75
Internet bill (May) 1 monthly ₱1,299.00 ₱1,299.00
Internet bill June) 1 monthly ₱1,299.00 ₱1,299.00
Load Card 2 pcs ₱2,000.00 ₱4,000.00
Contextualization seminar 12 pax ₱1,750.00 ₱21,000.00
Alcohol 35 1 liter bottles ₱120.54 ₱4,218.90
Hand soaps 35 packs ₱32.00 ₱1,120.00
Tissue roll 13 packs ₱145.00 ₱1,885.00
PPE (face shield) 35 pcs ₱50.00 ₱1,750.00
Foot bath 35 pcs ₱100.00 ₱3,500.00
Thermal scanner 3 Unit ₱1,868.57 ₱5,605.71

124,117.50
NOTE: ALL SIGNATURES MUST BE OVER PRINTED NAME
STOCKS REQUESTED ARE CERTIFIED TO BE FUNDS CERTIFIED AVAILABLE APPROVED:
WITHIN APPROVED PROGRAM:

JOHN REY C.VELASCO MARY BENETH G. LAGROMA ROBERT R. LEYSON

AGENCY PROPERTY SUPPLY OFFICER AGENCY CHIEF ACCOUNTANT Elementary School Principal llI

[ ] FUNDS DEPOSITED WITH PS [ ] _____________________CHECK No. __________________

IN THE AMOUNT OF: ____________________________________________________________________ (P____________________) ENCLOSED