CONFIRMATION SLIP

Name of Office: DIVINE MERCY FOUNDATION OF URDANETA CITY HOSPITAL

Address: 25 HS Drive, San Vicente West, Urdaneta City, Pangasinan

Contact Number: 09175002025

The following will attend the Quarter 3 Period 3 Mandatory TB Notification Data Validation Activity (January –
April - June 2022 & July – September 2022) on October 19 – 21, 2022 at Lafaayette Hotel, Baguio City. Session will
start on October 19, 2022, at 02:00 PM.

PLEASE
IF LIVE IN
CHECK
POSITION / MOBILE NO. & EMAIL
NAME GENDER CHECK CHECK
DESIGNATION ADDRESS LIVE LIVE
IN OUT
IN OUT
DATE DATE

TB DOTS
09212885488 
KATRINA B. ASUMIO F NURSE/HEAD 10/19/22 10/21/22
Batalier29@gmail.com
NURSE

09388125339 
XANDY GIRL D. EXIOMO F HEAD NURSE 10/19/22 10/21/22
Xandy.girlexiomo@gmail.com

We advise early submission of this form for hotel reservation. Reservations are only limited to the participants. Please be
reminded of the following:

Check – In Date: October 19, 2022 @ 2:00 PM

Check – Out Date: October 21, 2022 @ 12:00 Noon

Meals during travel and all transportation expenses incurred in relation to the activity will be reimbursed subject to allowable
rates. Allowed meal reimbursements are as follows:

October 19, 2022 – Breakfast, AM Snack, Lunch only (PC should include this if applicable)
October 19, 2022 – PM Snack only (PC should include this if applicable)

All terminal tickets, bus tickets and gasoline receipts must be submitted to our Finance Officer for proper reimbursement. If
by using your own vehicle, kindly indicate kilometer reading at the start (residence) and end of travel (venue). Reimbursement
will be made at the mileage rate (Mileage run divided by seven) times gasoline rate not to exceed the official receipt provided
in liquidation.

Take Note that for all Official Receipts, kindly indicate PHILCAT as the PAYEE.

NO TICKETS / NO OFFICIAL RECEIPTS, NO REIMBURSEMENT

Please email this form to angelpancho.philcat@gmail.com on or before September 20, 2022.

Accomplished by:

_ KATRINA B. ASUMIO _________10/13/22_________

Signature over Printed Name Date Accomplished