Reference Number: BatStateU-FO-PRO-02 Effectivity Date: May 14, 2021 Revision No: 03

Title: PURCHASE REQUEST FORM

Agency/ Batangas State University Date: June 14, 2021
Procuring (Central) Name of Project: Establishing Baseline Agriculture
Entity: Performance and Rural Development
Indicators Survey
Department Research, Development and Extension Services Project Location: BatStateU Central Administration (Rizal
/Office: Avenue, Extension Batangas City)
Section: Research PR No: PRO-2021-06-1-0434
UNIT ITEM DESCRIPTION QTY UNIT COST TOTAL COST
with Specifications
Extension, Programs, Activities and Projects (PAPS)
piece Long Plastic Envelop Clear 200 30.00 6,000.00

Office Supplies-Common Used Office Supplies and

Devices
box Ballpen Black, 12 pieces per box 17 132.00 2,244.00
ream Bond Paper 80gsm, A4 5 235.00 1,175.00
pack Filler 5 pcs per pack 80 50.00 4,000.00
piece ID Holder with Lace Ordinary 200 21.00 4,200.00
box Pencil #2, lead with eraser, 12 pieces per box 17 84.00 1,428.00

Office Supplies - Inks and Consumables

set Epson Ink Bottle L110 / L120 / L210 / L220 / L350 / L360 1 1,296.00 1,296.00
- Black, Cyan, Magenta, Yellow

TOTAL COST Php 20,343.00

Purpose: Supplies and Kits of Enumerators for the project "Establishing Baseline Agriculture Performance and Rural
Development Indicators Survey"

PRO-2021-06-1-0434 Page 1 of 2
 Prepared/Requested by: Certified Funds Available:

DR. ROMEL U. BRIONES MS. KATHLEEN F. FANOGA

Campus Director OIC-Assistant Director, Accounting

Date Signed: Date Signed:

Recommending Approval: Recommending Approval:

Included in the APP Complete Specifications

ENGR. ALBERTSON D. AMANTE ATTY. LUZVIMINDA C. ROSALES

Vice President for Research, Development and Extension Vice President for Administration and Finance
Services

Date Signed:
Date Signed:
Approved: Remarks:

DR. TIRSO A. RONQUILLO

University President

Date Signed:

Tracking Number:_____________

PRO-2021-06-1-0434 Page 2 of 2

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