CNOOC SES Ltd.

MEDICINE REQUEST FORM 2017 Form 17rev0

QHSE - Health

Deliver to : COSL 225 Cost Center : G550431 Date : April 22, 2017
Material Quantity Price per Sub Total
No Descr. Medicine name
Number Required order unit
1 1 70300057 12 EA 12 per BOX Visine 0.05% 6 ml Eye Drops 11,176 134,112 1
15 2 70301040 15 EA - BOX Voltaren 20 g Emulgel 59,226 888,390 15
1 3 70301141 1 BOX 50 per BOX Vometa 10 mg Flash Tablet 210,600 210,600 1
10 4 70300020 10 EA - BOX Wing Needle 15,904 159,040 10
1 5 70301125 1 BOX 30 per BOX Xanax 0.5 mg Xr (Extended Release) Tab 131,002 131,002 1
2 6 70301149 2 TB - BOX Xylocaine Jelly 2%, 10 g 61,628 123,256 2
1 7 70300188 100 EA 100 per BOX Zyloric 300 mg Tablet 4,815 481,500 1
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Total : 2,127,900.00

Requested by : Approved by : Note:

Name : Dr. Wahyu Satria Name : Akthur Febrian Sutanto

ID : 2002-9889 ID : 075231
Date : April 22, 2018 Date : April 22, 2018
CNOOC SES Ltd. MEDICINE REQUEST FORM 2017 Form 17rev0
QHSE - Health

Deliver to : COSL 225 Cost Center : G550431 Date : April 22, 2017
Material Quantity Price per Sub Total
No Descr. Medicine name
Number Required order unit
1 1 70300057 12 EA 12 per BOX Visine 0.05% 6 ml Eye Drops 11,176 134,112 1
20 2 70301040 20 EA - BOX Voltaren 20 g Emulgel 59,226 1,184,520 20
1 3 70301141 1 BOX 50 per BOX Vometa 10 mg Flash Tablet 210,600 210,600 1
10 4 70300020 10 EA - BOX Wing Needle 15,904 159,040 10
1 5 70301125 1 BOX 30 per BOX Xanax 0.5 mg Xr (Extended Release) Tab 131,002 131,002 1
2 6 70301149 2 TB - BOX Xylocaine Jelly 2%, 10 g 61,628 123,256 2
1 7 70300188 100 EA 100 per BOX Zyloric 300 mg Tablet 4,815 481,500 1
30 8 70301023 30 TU - BOX Benoson-M Cream 5 g 60,610 1,818,300 30
10 9 70301148 10 TU - BOX Fitajoint Roller Gell 35 g Gel 81,269 812,690 10
1 10 700006305 1 BOX 250 per BOX Neurobion 5000 Tablet 627,801 627,801 1
30 11 70301108 30 TU - BOX Scanderma 10 g Cream 21,073 632,190 30
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Total : 6,315,011.00

Requested by : Approved by : Note:

Name : Dr. Wahyu Satria Name : Akthur Febrian Sutanto

ID : 2002-9889 ID : 075231
Date : April 22, 2018 Date : April 22, 2018