OB Montessori Center OB Montessori Center

PROFESSIONAL HIGH SCHOOL PROFESSIONAL HIGH SCHOOL

Borrower’s Slip Borrower’s Slip

Date of Use: ___________________________________ Date of Use: ___________________________________

Student’s Name/s: ___________________________________ Student’s Name/s: ___________________________________
Level and Section: ___________________________________ Level and Section: ___________________________________
Teacher’s Name: ___________________________________ Teacher’s Name: ___________________________________

Material Quantity Remarks Material Quantity Remarks

Graduated cylinder 1 Graduated cylinder 1
Erlenmeyer flask 1 Erlenmeyer flask 1
Beaker 1 Beaker 1
Evaporating dish 1 Evaporating dish 1
Funnel 1 Funnel 1
Watch glass 1 Watch glass 1
Test tube with cork stopper 1 Test tube with cork stopper 1
Test tube rack 1 Test tube rack 1
Thermometer 1 Thermometer 1
Pipette 1 Pipette 1
Stirring rod 1 Stirring rod 1
Alcohol lamp 1 Alcohol lamp 1
Spatula 1 Spatula 1
Dropper 1 Dropper 1
Bunsen burner 1 Bunsen burner 1
Tripod 1 Tripod 1
Wire gauze 1 Wire gauze 1
Aspirator 1 Aspirator 1
Timer 1 Timer 1
Forceps 1 Forceps 1
Test tube brush 1 Test tube brush 1
Wash bottle 1 Wash bottle 1

Group Representative: _______________________________ Group Representative: _______________________________

Name and Signature Name and Signature

----------------------------------------------- -----------------------------------------------
To be accomplished by the laboratory custodian/teacher: To be accomplished by the laboratory custodian/teacher:

Status of returned materials Yes No Status of returned materials Yes No

Complete ▢ ▢ Complete ▢ ▢
Incomplete* ▢ ▢ Incomplete* ▢ ▢
Broken* ▢ ▢ Broken* ▢ ▢
*Note in the Remarks the missing or broken material *Note in the Remarks the missing or broken material

Authorized Personnel: _______________________________ Authorized Personnel: _______________________________

Name and Signature Name and Signature