Purchase Requisition Form: Total

PR NO :
PO NO :
PURCHASE REQUISITION FORM
REQUESTOR UNIT : Gizi X RS BSM
SUGGESTED VENDOR Requested by

: tiwi
QUOTATION REF/NO : Requested date
: 02/02/2019 sd 07/02/2019
CURRENCY :
TYPE OF REQUEST : CAPEX OPEX
LEVEL OF URGENCY : x REGULAR URGENT
Expected
No. Type GL Code Description QTY Price/unit Total Delivery
Date
1 ayam broiler 5 40,000 200,000
2 Ikan tongkol 2 50,000 100,000
3 Telur Ayam 3 25,000 75,000
4 telur puyuh 1 15,000 15,000
5 ayam fillet 0,5 50,000
6 bakso 1 25,000 25,000
7 jamur 1 10,000 10,000
8 kentang 0,5 20,000
9 wortel 1 30,000
10 kacang panjang 2 5,000 10,000
11 buncis 0,25 15,000
12 labu 2 5,000 10,000
13 oyong 2 5,000 10,000
14 sawi putih 1 25,000
15 caisin 4 5,000 20,000
TOTAL 615,000
JUSTIFICATION
* Use extra sheet as attachment for request with more than 10 items / services.
CATEGORY (Please check one) UNIT APPROVAL HO APPROVAL RECEIVED
MANAGER
REQUESTOR LOGISTIC PURCHASING FINANCE DIRECTOR PURCHASING FIN DIRECTOR CEO PROCUREMENT FINANCE
FIXED ASSET: REQUESTOR
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE
FURNITURE & FIXTURES
BUILDING IMPROVEMENT
PR NO :
PO NO :
PASIEN

: ivana
: 29/01/2021 sd 04/02/2021
CURRENCY :
Expected
No. Type GL Code Description QTY Satuan Price/unit Total Delivery
Date
1 ayam broiler 3.0 ekor 40,000 120,000
2 Ikan patin 3.0 kg 25,000 75,000
3 Telur Ayam 1.0 kg 30,000 30,000
4 telur puyuh 2.0 kg 35,000 70,000
5 tempe 1.0 buah 12,000 12,000
6 Tofu 3.0 bks 8,000 24,000
7 wortel 0.5 kg 25,000 12,500
8 buncis 0.5 kg 30,000 15,000
9 labu siam 1.0 kg 12,000 12,000
10 bayam 4.0 ikat 4,000 16,000
11 caisin 4.0 ikat 3,500 14,000
12 Daging 1.0 kg 120,000 120,000
14 Bumbu dapur 1.0 bks 15,000 15,000
15 pokcoy 4.0 ikat 5,000 20,000
16 melon 2.0 kg 23,000 46,000
17 pepaya 2.0 kg 13,000 26,000
18 pisang 3.0 sisir 15,000 45,000
19 semangka 2.0 kg 10,000 20,000
20 selada 1.0 ikat 6,000 6,000
21 daun bawang 1.0 ikat 5,000 5,000
22 daun seledri 1.0 ikat 5,000 5,000
23 tahu 2.0 bungkus 10,000 20,000

PR NO : 728,500
PO NO :

: ivana
: 29/01/2021 sd 04/02/2021
CURRENCY :

Expected
Date
24 Apel 1.0 kg 30,000 30,000
25 Parselay 1.0 ikat 5,000 5,000
26 Bawang goreng 1.0 bks 22,000 22,000
27 Rolade 1.0 bks 18,000 18,000
28 Ayam fillet 0.5 kg 56,000 28,000
29 Brokoli 0.5 kg 30,000 15,000
30 Bunga kol 0.5 kg 35,000 17,500
TOTAL 864,000
135,500
JUSTIFICATION
MANAGER
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE

POLI

: ivana
: 29/01/2021 sd 04/02/2021
CURRENCY :
Expected
Date
1 Vit Gelas 5.0 Dus 20,000 100000
TOTAL 100,000
JUSTIFICATION
MANAGER
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE
PR NO :
PO NO :

DOKTER JAGA

: ivana
QUOTATION REF/NO : Requested date : 29/01/2021 sd 04/02/2021
CURRENCY :
Expected
Date
1 ayam broiler 1.0 ekor 35,000 35,000
2 Ikan patin 1.0 kg 25,000 25,000
3 telur puyuh 0.5 kg 35,000 17,500
4 Wortel 0.3 kg 24,000 6,000
5 caisin 2.0 ikat 4,000 8,000
6 brokoli 0.5 kg 32,000 16,000
7 bayam 2.0 ikat 5,000 10,000
8 putren 1.0 bks 10,000 10,000
9 tahu 1.0 bks 10,000 10,000
10 tempe 0.5 bks 12,000 6,000
11 Roti 1.0 bks 18,500 18,500
12 Daging Sapi 0.5 kg 100,000 50,000
13 Telur Ayam 1.0 kg 27,000 27,000
14 Tofu 1.0 bks 9,000 9,000
15 Pokcoy 2.0 bks 5,000 10,000
16 Sawi putih 1.0 bks 10,000 10,000
17 Tofu 2.0 bks 10,000 20,000
TOTAL 288,000
JUSTIFICATION
MANAGER
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE
PR NO :
PO NO :

CURRENCY :
Expected
Date
15 pokcoy 4.0 ikat 5,000 20,000
16 bayam 2.0 ikat 5,000 10,000
17 putren 1.0 bks 10,000 10,000
18 jamur 2.0 cup 10,000 20,000
20 tahu 2.0 bks 10,000 20,000
21 tempe 1.0 bks 12,000 12,000
TOTAL 92,000
JUSTIFICATION
MANAGER
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE
PR NO :
PO NO :
DOKTER SPESIALIS
SUGGESTED VENDOR Requested by : ivana
QUOTATION REF/NO : Requested date : 29/01/2021 sd 04/02/2021

CURRENCY :
Expected
Date
1 melon 2.0 kg 23,000 46,000
2 pepaya 2.0 kg 13,000 26,000
3 semangka 1.0 kg 14,000 14,000
4 Pisang 2.0 sisir 15,000 30,000
5 Donat 1.0 bks 18,000 18,000
6 Anggur 2.0 kg 26,000 52,000
7 Kentang 1.0 kg 22,000 22,000
TOTAL 208,000
JUSTIFICATION
MANAGER
MEDICAL EQUIPMENT
COMPUTER & IT
MACHINERY
VEHICLE

Purchase Requisition Form: Total

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Purchase Requisition Form: Total

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PR NO :

PURCHASE REQUISITION FORM

REQUESTOR UNIT : Gizi X RS BSM

SUGGESTED VENDOR Requested by

TYPE OF REQUEST : CAPEX OPEX

LEVEL OF URGENCY : x REGULAR URGENT

1 ayam broiler 5 40,000 200,000

2 Ikan tongkol 2 50,000 100,000

3 Telur Ayam 3 25,000 75,000

4 telur puyuh 1 15,000 15,000

5 ayam fillet 0,5 50,000

6 bakso 1 25,000 25,000

7 jamur 1 10,000 10,000

8 kentang 0,5 20,000

10 kacang panjang 2 5,000 10,000

11 buncis 0,25 15,000

12 labu 2 5,000 10,000

13 oyong 2 5,000 10,000

14 sawi putih 1 25,000

15 caisin 4 5,000 20,000

PURCHASE REQUISITION FORM

REQUESTOR UNIT : Gizi X RS BSM

SUGGESTED VENDOR Requested by

TYPE OF REQUEST : CAPEX OPEX

LEVEL OF URGENCY : x REGULAR URGENT

1 ayam broiler 3.0 ekor 40,000 120,000

2 Ikan patin 3.0 kg 25,000 75,000

3 Telur Ayam 1.0 kg 30,000 30,000

4 telur puyuh 2.0 kg 35,000 70,000

5 tempe 1.0 buah 12,000 12,000

6 Tofu 3.0 bks 8,000 24,000

7 wortel 0.5 kg 25,000 12,500

8 buncis 0.5 kg 30,000 15,000

9 labu siam 1.0 kg 12,000 12,000

10 bayam 4.0 ikat 4,000 16,000

11 caisin 4.0 ikat 3,500 14,000

12 Daging 1.0 kg 120,000 120,000

14 Bumbu dapur 1.0 bks 15,000 15,000

15 pokcoy 4.0 ikat 5,000 20,000

16 melon 2.0 kg 23,000 46,000

17 pepaya 2.0 kg 13,000 26,000

18 pisang 3.0 sisir 15,000 45,000

19 semangka 2.0 kg 10,000 20,000

20 selada 1.0 ikat 6,000 6,000

21 daun bawang 1.0 ikat 5,000 5,000

22 daun seledri 1.0 ikat 5,000 5,000

23 tahu 2.0 bungkus 10,000 20,000

PURCHASE REQUISITION FORM

REQUESTOR UNIT : Gizi X RS BSM

SUGGESTED VENDOR Requested by

TYPE OF REQUEST : CAPEX OPEX

24 Apel 1.0 kg 30,000 30,000

25 Parselay 1.0 ikat 5,000 5,000

26 Bawang goreng 1.0 bks 22,000 22,000

27 Rolade 1.0 bks 18,000 18,000

28 Ayam fillet 0.5 kg 56,000 28,000

29 Brokoli 0.5 kg 30,000 15,000

30 Bunga kol 0.5 kg 35,000 17,500

REQUESTOR UNIT : Gizi X RS BSM

SUGGESTED VENDOR Requested by

TYPE OF REQUEST : CAPEX OPEX

LEVEL OF URGENCY : x REGULAR URGENT

1 Vit Gelas 5.0 Dus 20,000 100000