APR FORM revised May 2015 FORM NO.

002
NAME AND ADDRESS OF DAGAT-DAGATAN ELEMENTARY SCHOOL AGENCY ACCT. CODE
REQUESTING AGENCY AGENCY CONTROL No.
TEL. NOS.

AGENCY PROCUREMENT REQUEST PS APR No.

To: PROCUREMENT SERVICE 4-Nov-21

DBM Compound, RR Road (Date Prepared)
Cristobal St., Paco, Manila

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) [ ] Others, pls. specify_______________
[ ] Certificate of Budget Allocation (CBA) [ ] Payment _______________________________

This form shall be prepared for requisitions of Common-Use goods from the PS Depots & Sub-Depots; and for orders of Consumables
& Non-Common Use Supplies from the PS Main.
For PS Main-Common Use Supplies, please use Form 001 R or Form 001 B
ITEM ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK No. QUANTITY UNIT UNIT PRICE AMOUNT
No.
1 Powdered Ink for xerox kyocera 2 pcs 2,579.00 5,158.00
2 664 Ink set 2 set 850.00 1,700.00
3 Ink ordinary blk 7 pcs 85.00 595.00
4 A4 Bond Paper 31 pcs 131.00 4,061.00
5 Long bond apper 33 pcs 130.00 4,290.00
6 Calculator 1 pcs 304.83 304.83
7 003 Black Ink 6 pc 260.00 1,560.00

TOTAL AMOUNT ₱ 17,668.83

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

ERLINDA L. BERNARDO JENELYN V. VELASCO YOLANDA L. VALDIZNO

AGENCY HEAD/AUTHORIZED SIGNATURE
AGENCY PROPERTY/SUPPLY OFFICER AGENCY CHIEF ACCOUNTANT

[ ] FUNDS DEPOSITED WITH PS [ ] ___________________ CHECK No. ____________________

IN THE AMOUNT OF: ____________________________________________________________ (P _____________________) ENCLOSED