NAME AND ADDRESS OF REQUESTING AGENCY

DepED - Division of Surigao del Sur

(School)

Page 1 of 1 AGENCY ACCT. CODE AGENCY CONTROL No. PS APR No.

AGENCY PROCUREMENT REQUEST

To: THE PROCUREMENT SERVICE DBM - CARAGA Region J. Rosales Avenue City Hall Drive, Butuan City

(Date Prepared)

PLEASE CHECK ( / ) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM 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 [ ] Charged to Unutilized Deposit, APR No. __________ Dated: ______________

] 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 OF ORIGINAL COPY

ITEM NO. ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK NO. QUANTITY UNIT Unit Price AMOUNT

Total AMOUNT NOTE : ALL SIGNATURES MUST BE OVER PRINTED NAME STOCKS REQUESTED ARE CERTIFIED TO BE WITHIN APPROVED PROGRAM: FUNDS CERTIFIED AVAILABLE:APPROVED:

AGENCY PROPERTY SUPPLY OFFICER

AGENCY CHIEF ACCOUNTANT

AGENCY HEAD/AUTHORIZED SIGNATURE

] FUNDS DEPOSITED WITH PS [ ] _________________ CHECK No. ______________ IN THE AMOUNT OF ___________________________________________ (P _______________) ENCLOSED