APR Form Revised March 2007

NAME AND ADDRESS

OF REQUESTING
AGENCY
TEL. NOS.

SAYAO PRIMARY SCHOOL

Sayao, Kabasalan, Zamboanga Sibugay
DEPARTMENT OF EDUCATION

AGENCY
ACCT. CODE
AGENCY CONTROL No.
PS APR No.

AGENCY PROCUREMENT REQUEST

To:

THE PROCUREMENT SERVICE

Department of Budget and Management
Zamboanga City Depot

(Date Prepared)

PLEASE CHECK () APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM/S LISTED BELOW
[ ] Please issue common-use supplies/materials per Price List No. _____________________________ dated________________________
Mode of delivery: [ ] Pick-up (Fast Lane)
[ ] Pick-up (Schedule)
[ ] Delivery (door-to-door)
In case fund is not sufficient: [ ] Reduce Quantity

[ ] Bill Us

[ ] Charge to Unutilized Deposit, APR No. _______________ Date _________

[ ] Please purchase for our agency non-common items. Attached herewith:

[ ] Complete Specifications
[ ] Obligation Request (ObR)
[ ] Certificate of Budget Allocation (CBA)
[ ] Payment

[ ] Others, pls. specify_____________

_____________________________

IMPORTANT!! PLEASE SEE THE INSTRUCTIONS/CONDITIONS AT THE BACK HEREOF

ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK No.
QUANTITY
Unit
Unit Price
SF 1
50
piece
SF 2
30
piece
SF 3
50
piece
SF 4
27
piece
SF 7
50
piece
Photocopy Testpaper (Pre and Post)
550
piece
500
Photocopy Phil-IRI (Pre and Post)
set
240
Photocopy SREA (Pre and Post)
piece
EGRA (Pre and Post)
240
piece
Photocopy of Reports
900
piece
Tarpulin
1
piece
Class Record
5
piece
Lesson Plan
5
piece
Ballpen Black and Red (My Gel)
12
box
Staple Wire
1
box
Charol
1
roll
Mefinamic
1
pack
Betadine
3
bottle
Alcohol
3
bottle
Cotton
1
pack
Plaster
3
pack
Quickdry Enamel Paint
5
gallon
Quickdry Latex Paint
5
gallon
Tinting Color Assorted
5
pint
Paint Thinner
1
gallon
Paint Brush
4
piece
Roller Brush
4
piece
gas
10
liter
oil (2t)
2
oz
nylon
1
roll
bulb
1
piece
kwz
Electric Bill
1
Transportation Allowance
1
Training/Seminars
1
Total AMOUNT
NOTE: ALL SIGNATURES MUST BE OVER PRINTED NAME
STOCKS REQUESTED ARE CERTIFIED TO BE
FUNDS CERTIFIED AVAILABLE
APPROVED:
ITEM No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

AMOUNT
-

WITHIN APPROVED PROGRAM:

EMMABEL M. OMEREZ

DENNIS M. YAPE

DENNIS M. YAPE

AGENCY PROPERTY SUPPLY OFFICER

AGENCY CHIEF ACCOUNTANT

AGENCY HEAD/AUTHORIZED SIGNATURE

[ ] FUNDS DEPOSITED WITH PS

[ ] _____________________CHECK No. __________________
IN THE AMOUNT OF: ____________________________________________________________________ (P____________________) ENCLOSED