PAYMENT REQUEST FORM

Date June 06, 2023

Acctg. PRF Ctrl No.

PAYABLE TO EXXTRA GAS STATION

PAYMENT Currency ______ Amount 46,388.79 PAYMENT MODE Check Remittance / TT

PAYMENT TERMS DATE NEEDED 06-Jun-23

BANK NAME/BRANCH/ACCOUNT NO.

PURPOSE & CHARGING DETAILS

EXXTRA GAS STATION FUEL DATED MAY 16-31 2023

With Budget Without Budget
(If w/o budget, kindly specify what account
will be offsetted for this transaction)

REQUESTOR
Issued by: Checked by: Approved by: Verified by: Approved for Payment:

ANTHONY C. RECILLA ELMER IAN PARIS

Requestor Immediate Superior Manager CCO/CFO Finance CEO
= & Php20K below above Php20K Php20K above

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