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Region: III____________________________________________________________________

Province: TARLAC _________________________________________________________________


City/Municipality: TARLAC CITY____________________________________________________________

Area/Description of Materials Unit Quantity Remarks


Barangay Enumeration Area
Number/Questioners Forms, Manuals, Transmitted Received
Equipment and Supplies
(1) (2) (3) (4) (5)
ERASE
PENCIL
SHARPENER
FACE SHIELD
UNIFORM (BLUE)
UNIFORM (PINK)
VEST
CAP
CLIP BOARD
FORMS
BOOKLET 1
BOOKLET 2
BOOKLET 3
BOOKLET 6

Transmitted by: Received by:

___________Van P. PagdiLAO ROMULO E. GALANG JR.


SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

__________CAS_____________ ______T.S_____
POSITION/DESIGNATION POSITION/DESIGNATION

08/31 _________08/31____________
DATE DATE

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