NAME AND ADDRESS: FELIX H.

RODA AGENCY
OF REQUESTING: LACUPAYAN ELEMENTARY SCHOOL ACCT. CODE
AGENCY: DEPED AGENCY CONTROL No.
TEL. NOS.: PS APR No. 00
AGENCY PROCUREMENT REQUEST
To: THE PROCUREMENT SERVICE
Department of Budget and Management (Date Prepared)
Zamboanga Sibugay Province

PLEASE CHECK (∕) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM/S LISTED BELOW.
[ ] Please issue common-use supplies/ materials per Orice List No. __________________ dated _________________________
Mode of delivery: [ ] Pick-up (Fast Lane) [ ] Pick-up (Schedule) [ ] Delivery (door-to door)

In case fund is not suffecient: [ ] Reduce Quantity [ ] Bill Us [ ] Charge to Unutilized Deposit, APR No. ____ Date _____

[ ] Please purchase for our agency non-common items. Attache 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
E-5025 Printer 3 IN 1 1 unit 14,736.84 14,736.84
A-1003 Notebook 80 leaves 180 dozen 27.36 4,924.80
A-1057 Pad paper 105 pad 31.57 3,314.85
A-1004 Intermediate pad 80 pad 35.78 2,862.40
A-1015 Ballpen black 80 pieces 7.36 588.80
A-1016 Sharpener 82 pieces 10.52 862.64
A-1011 Bond paper long S-20 6 ream 263.15 1,578.90
A-1020 Bond paper A4 3 ream 252.63 757.89
A-1005 Fastener 5 box 63.15 315.75
A-1039 Pencil Monggol 2 40 box 157.89 6,315.60
A-1041 Crayons 12s 165 box 21.05 3,473.25
A-1057 Ruler 175 pieces 10.52 1,841.00
X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X

TOTAL AMOUNT P
NOTE: ALL SIGNATURIES MUST BE OVER PRINTED NAME
STOCKS REQUESTED BY: FUNDS AVAILABLE APPROVED:

FERNANDO D. ALICAYA FELIX H. RODA FELIX H. RODA

Designate Supply Officer Elementary School Head Elementary School Head
[ ] FUNDS DEPOSITED WITH PS [ ] ______________ CHECK No. ______________
IN THE AMOUNT OF: _____________________________________________________ (P _______) ENCLOSED