ACADEMIC AFFAIRS OFFICE

[ X ] Main [ ] Branch
BORROWER’S SLIP
(Laboratory/Instructional Resource Center/Media Resource Center)

Date of Filing: January 10, 2024 Course: Subject: Code:

BCHE 222L Physical Chemistry 1 6072
Name of Teacher: Edna D. Quinto Name of Borrower:
Gershon M. Antolijao
College/Office: College of Engineering Education
Schedule/Date of Use:

SPECIFICATION Date Date

Quantity Status Status Remarks
(Please write legibly) Released Returned
EQUIPMENT:
1. 25 mL Pycnometer 1
2. Analytical balance 1
3. Thermometer 1
4. Pipette 1
5.
MATERIALS/SUPPLIES:
1. Ethanol ethyl acetate or acetone 25 mL
2.
3.
4.
5.
6.
7.
8.
9.
10.
Legend: 1 – Good Condition 2 – For Replacement 3 – For Repair 4 - Consumable
Requested & received by: Approved & released by: Returned by: Checked by:

GERSHON M. ANTOLIJAO GERSHON M. ANTOLIJAO

Name & Signature/Date Laboratory Custodian/Date Name & Signature/Date Name & Signature/Date
Remarks: Remarks: Remarks: Remarks:

TERMS AND CONDITIONS:

1. Reservation must be placed three (3) days before the scheduled activity; where applicable. Approval shall be on a “FIRST COME FIRST
SERVED”.
2. The borrowed equipment and/or materials & supplies shall be used only within the premises of the school.
3. The item/s borrowed are presumed to be in working condition at the time of release, and expected to be returned of the same
condition.
4. The faculty/borrower shall be automatically liable over the borrowed item/s and assumes the following responsibilities:
4.1 Caring and handling of the equipment/materials/supplies;
4.2 Returning the borrowed item/s before the due date and/or after use;
4.3 Doing the AFTER-CARE before returning; and
4.4 Replacing or paying for damaged or lost item/s
5. An “Incident Report” shall be made immediately for any loss/damage done to the borrowed equipment/materials.
6. No student shall be allowed to withdraw and/or return the equipment/materials borrowed without the presence of the subject
teacher.

I HEREBY AGREE WITH THE TERMS AND CONDITIONS STATED ABOVE.

GERSHON M. ANTOLIJAO Edna D. Quinto, Ph.D.

Borrower’s Name & Signature/Date Subject Teacher’s Name & Signature/Date

F-13050-009/ Rev. #6/ Effectivity: July 23, 2021