Agency: SK Brgy.

Molpolo Agency Code:

Address: Molopolo, Macrohon, Southern Leyte Control No.:
Contacts: PS APR No.:
AGENCY PROCUREMENT REQUEST FORM PS APR No.:

PROCUREMENT SERVICE DATE:

SOUTHERN LEYTE SUB-DEPOT
ASUNCION, MAASIN CITY, SOUTHERN LEYTE

ACTION ON THE ITEM(S) LISTED BELOW

( ) Please furnish us with price estimate (for office equipment/furniture & supplemental items)
( ) Please furnish for our agency the equipment/furniture/supplemental items per your price
Estimate (PS RAD No. ________________) attached _______________________
( ) Please issue common – use supplies/materials per PS price less as of ________________
( ) Please issue Certificate of Price Reasonabless
( ) Please furnish us with your latest/update price list
( ) Others (Specify)
NOTE: Check payment PROCUREMENT SERVICE
ITEM ITEM DESCRIPTION/SPECIFICATION QTY UNIT UNIT PRICE AMOUNT
CODE STOCK NO

TOTAL AMOUNT
NOTE: ALL SIGNATURE MUST BE OVER PRINTED NAMES
STOCK REQUESTED ARE CERTIFIED TO BE WITH FUNDS CERTIFIED AVAILABLE APPROVED
APPROVED PROGRAM

_________________________________ ____________________________ ELJUN M. ARQUITA

AGENCY PROPERTY SUPPLY OFFICER _ AGENCY HEAD AUTHORIZED SIGNATURE
AGENCY CHIEF ACCOUNTANT
( ) FUNDS DEPOSIT WITH PS ( ) CHECK NO.

IN THE AMOUNT OF _______________________________________________________________________________( P

___________________________) ENCLOSED