Annex A
Republic of the PhilippinesProvince of Quezon
Lucena City
OBLIGATION REQUESTNo.
Payee GODWIN LADLAD, ET AL.
Office PROVINCIAL ENGINEER'S OFFICE
Address Brgy. Talipan, Pagbilao, Quezon
Particulars F. P. P. Amount
PER DIEM Php 15,000.00Godwin Ladlad - Php 5,440.00Lysander Ladlad - Php 2,300.00Edwin Matienzo - Php 1,920.00Ricardo Gollena - Php 2,620.00Fernando Llaneta - Php 2,720.00
TOTAL Php 15,000.00
TOTAL Php 15,000.00A. Certified B. Certified
Charges to appropriation/allotment necessary, lawful Existence of available appropriationand under my direct supervision
Supporting documents valid, proper and legal
Signature Signature
Printed Name CESARIO T. PALAYAN Printed Name GODOFREDO E. MATIENZO
PositionProvincial Engineer
PositionProvincial Budget Officer
Head, Requesting Office/Authorized Representative Head, Budget Unit/Autorized Representative
Responsibility Center
Account Code
Date Date
Standard Form No: SF-GOOD-58Revised on: May 24, 2004
PURCHASE ORDERProvince of Quezon
LGU
SUPPLIER : MAVIL PETRON SERVICE CENTER P.O. NO. :Address : Diversion Road, Silangang Mayao, Lucena City DATE :E-Mail Address :Telephone No. : PR No./s :TIN :
Gentlemen:Please furnish this office the following articles subject to the terms and conditions contained herein:
Place of Delivery : Delivery Term :Date of Delivery: Payment Term :
Unit. Qty. Description Unit Cost Total Cost
PR. NO. March 17-21, 2008
Liters 60 Diesel P 38.69 P 2, 321.40Liter 1 Brake Fluid 277.00 277.00Pail 1 Oil #10 1, 879.00 1, 879.00
March 22-28, 2008
Liters 444 Diesel 39.19 16, 851.70Liters 14 XCS Gasoline 46.96 657.44
March 29-Aapril 7, 2008
Liters 315 Diesel 39.69 12, 281.70April 8, 2008
Liters 430 Diesel 40.19 17, 281.70Pc 1 Brake Fluid (250 ml) 88.00 88.00
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Fifty one thousand eight hundred fifty eight pesos & fifty nine centavos only P P 51, 858.59(Total Amount in Words)
Approved:
RAFAEL P. NANTESConforme: Governor
MONICO VILLANUEVA(Signature over Printed Name)
(Date)
Obligation of Allotment : Funds Available
EVANGELINA M. ONG FELIX L. HABITOProvincial Accountant Provincial Treasurer
Amount : _______________Allotment No.: ___________
Mode of Procurement:
Stock No.
In case of failure to make the full delivery within the time specified above, a penalty of one-tenth (1/10) of one percent for every day of delay shall be imposed.
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
PROVINCIAL GOVERNMENT OF QUEZONAgency / Procuring Entity
Department Provincial General Services Office PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
rms Copy Paper Short 100 275.00 27,500.00
rms Copy Paper Long 100 285.00 28,500.00
bxs Ballpen Blue 2 275.00 550.00
pcs Folders Long 300 4.50 1,350.00
ink Cartridge Ink for HP 21 3 1,200.00 3,600.00
ink Cartridge Ink for HP 22 3 1,400.00 4,200.00
ink Cartridge Ink for HP 27 5 1,350.00 6,750.00
ink Cartridge Ink for HP 28 5 1,650.00 8,250.00
ink Cartridge Ink for HP 74 5 1,100.00 5,500.00
ink Cartridge Ink for HP 75 5 1,250.00 6,250.00
ink Cartridge Ink for HP 15A 1 3,950.00 3,950.00
packs Laid Board Short 30 38.00 1,140.00
box Pentel Pen 1 540.00 540.00
pcs Record Book 5 65.00 325.00
bxs Sign Pen / High Tech Pen 1.5 3 260.00 780.00
tube Toner - Xerox Machine 2 4,500.00 9,000.00
xxxxxxxxxxxxxx 108,185.00
P 108,185.00
Purpose / Remarks: For use in the office of the Provincial General Services
Requested by: Approved by:
Signature:
Printed Name: MERCEDES O. PORNELA RAFAEL P. NANTES
Designation Executive Assistant III / Acting APGDH - PGSO Provincial Governor
Date:
Standard Form Title: Purchase Request
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
PROVINCIAL GOVERNMENT OF QUEZONAgency / Procuring Entity
Department Janitorial Services - PGSO PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
bot Air fresherner 12 245.00 2,940.00
bot Alcohol 12 68.00 816.00
bot Cleanser, big 15 45.00 675.00
bot Dish Washing Liquid, Joy 15 68.00 1,020.00
cans Disinfectant Spray, Baygon 15 275.00 4,125.00
cans Insecticide 12 285.00 3,420.00
kilo Powder Soap 6 165.00 990.00
gal Muriatic Acid 10 145.00 1,450.00
pcs Toilet Deodorant 15 43.00 645.00
packs Tissue Paper , 2 ply Joy 12 180.00 2,160.00
pcs Trash Bag 200 7.00 1,400.00
pcs Brown Tambo 12 95.00 1,140.00
pcs Brown Tingting 50 18.00 900.00
pcs Dust Pan 12 65.00 780.00
pcs Mop Handle - Screw Type 10 275.00 2,750.00
pcs Mop Head - all cotton 20 55.00 1,100.00
pcs Plastic Pail 10 85.00 850.00
pcs Rag 15 45.00 675.00
pcs Scouring Pad 12 65.00 780.00
doz Soap 2 420.00 840.00
pcs Tabo 10 20.00 200.00
pcs Toilet Bowl Brush 14 35.00 490.00
pcs Door Knob 3 385.00 1,155.00
packet Battery - Size AA 5 37.10 185.50
pcs Padlock 10 120.00 1,200.00
xxxxxxxxxxxxxx 32,686.50
TOTAL P 32,686.50
Purpose / Remarks: FOR USE IN THE OFFICE OF THE PROVINCIAL GENERAL SERVICES
Requested by: Approved by:
Signature:Printed Name: MERCEDES O. PORNELA RAFAEL P. NANTESDesignation Executive Assistant III / Acting APGDH - PGSO Provincial GovernorDate:
Standard Form Title: Purchase Request
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
PROVINCIAL GOVERNMENT OF QUEZONAgency / Procuring Entity
Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
bot Air freshener 12 245.00 2,940.00
bot Alcohol 12 68.00 816.00
bot Cleanser, big 15 45.00 675.00
bot Dish Washing Liquid, Joy 15 68.00 1,020.00
cans Disinfectant Spray, Baygon 15 275.00 4,125.00
cans Insecticide 12 285.00 3,420.00
kilo Powder Soap 6 165.00 990.00
gal Muriatic Acid 10 145.00 1,450.00
pcs Toilet Deodorant 15 43.00 645.00
packs Tissue Paper , 2 ply Joy 12 180.00 2,160.00
pcs Trash Bag 200 7.00 1,400.00
pcs Broom Tambo 12 95.00 1,140.00
pcs Broom Tingting 50 18.00 900.00
pcs Dust Pan 12 65.00 780.00
pcs Mop Handle - Screw Type 10 275.00 2,750.00
pcs Mop Head - all cotton 20 55.00 1,100.00
pcs Plastic Pail 10 85.00 850.00
pcs Rag 15 45.00 675.00
pcs Scouring Pad 12 65.00 780.00
doz Soap 2 420.00 840.00
pcs Dipper 10 20.00 200.00
pcs Toilet Bowl Brush 14 35.00 490.00
pcs Door Knob 3 385.00 1,155.00
packs Battery - Size AA 5 37.10 185.50
pcs Padlock - Heavy Duty 10 120.00 1,200.00
xxxxxxxxxxxxxx 32,686.50
TOTAL P 32,686.50
Purpose / Remarks: FOR USE IN THE OFFICE OF THE PROVINCIAL GENERAL SERVICES
Requested by: Approved by:Signature:Printed Name: MERCEDES O. PORNELA RAFAEL P. NANTES
Designation Executive Assistant III / Acting APGDH - PGSO Provincial GovernorDate:
Standard Form Title: Purchase Request
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
Agency / Procuring Entity
Department Provincial Engineer's Office PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
March 17-21, 2008
Liters Diesel 60 P 38.69 P 2, 321.40
Liter Brake Fluid 1 277.00 277.00
Pail Oil #10 1 1,879.00 1,879.00
March 22-28, 2008Liters Diesel 444 39.19 16,851.70
Liters XCS Gasoline 14 46.96 657.44
March 29-Aapril 7, 2008Liters Diesel 315 39.69 12,502.35
April 8, 2008Liters Diesel 430 40.19 17,281.70
Pc Brake Fluid (250 ml) 1 88.00 88.00
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
TOTAL P 51, 858.59
Purpose / Remarks: For use in Equipment Pool Operations & Management Services
Requested by: Approved by:Signature:
Printed Name: RAFAEL P. NANTES RAFAEL P. NANTES
Designation Provincial Governor Provincial Governor
Date:
Standard Form Title: Purchase Request
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
Provincial Government of QuezonAgency / Procuring Entity
Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
pcs. Philippine Flag 7' x 13' 8 3,800.00 30,400.00x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-
TOTAL P 30,400.00
Purpose / Remarks: FOR USE AT PEREZ PARK
Requested by: Approved by:Signature:Printed Name: RAFAEL P. NANTES
Designation Provincial Governor
Date:
Standard Form Title: Purchase Request
MERCEDES O. PORNELA Executive Assistant III
Acting APGDH-PGSO
Standard Form No: SF-GOOD-59Revised on: May 24, 2004
PURCHASE REQUEST
Agency / Procuring Entity
Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
11/5/2007 ltrs. Petron Diesel ### 1,000.0011/9/2007 ltrs. Shell Diesel 51.54 1,878.63
11/14/2007 ltrs. Shell Diesoline 40.11 1,492.1011/16/2007 Body Wash, Vacuum 100.0011/19/2007 ltrs. Shell Diesel ### 1,667.0511/21/2007 Body Wash 50.00
Vacuum 50.00Setting 120.00Carpet Shampoo 120.00Wax 100.00
11/23-24/07 ltrs. Petron Diesel ### 1,500.0011/27/2007 ltrs. Shell Diesoline ### 1,322.4611/29/2007 ltrs. Petron Diesel ### 1,869.30
Parking & Toll Fees 772.00x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-
TOTAL P 12,041.54
Purpose / Remarks: FOR USE OF SFN-303 ASSIGNED TO THE PROVINCIAL GENERAL SERVICES OFFICER.
Requested by: Approved by:Signature:Printed Name: EXALTACION Q. ANGELES RAFAEL P. NANTES
Standard Form Title: Purchase Request
Designation Provincial General Services Officer Provincial GovernorDate:
ACCEPTANCE & INSPECTION REPORTProvincial Government of Quezon
LGU
Supplier A / R No.PO No. Date Invoice No. DateRequisitioning Office/Dept.
Item No. Unit Description QuantityMarch 17-21, 2008
Liters Diesel 60Liter Brake Fluid 1Pail Oil #10 1
March 22-28, 2008Liters Diesel 444Liters XCS Gasoline 14
March 29-Aapril 7, 2008Liters Diesel 315
April 8, 2008Liters Diesel 430
Pc Brake Fluid (250 ml) 1XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Date Received: Date Inspected:
XXXXXXXX Complete
Partial
Inspection Office/Committee
Asst. Provincial Engineer - EPOMS INSPECTED & VERIFIED BY:OIC
CESARIO T. PALAYAN EVANGELINA M. ONGHead of Office PAO Representative Provincial Accountant
Noted:ICU Representative
MERCEDES O. PORNELAC FELIX L. HABITO
Acting APGDH-PGSO PTO Representative Provincial Treasurer
Inspected, verified and found OK As to quantity and specifications
REO-AMBROSIO MAAÑO III
ANNEX G-7
ACCEPTANCE & INSPECTION REPORTProvincial Government of Quezon
LGU
Supplier Gino's Marketing A / R No.
PO No. Date Invoice No. Date
Requisitioning Office/Dept. MMDH-LOPEZ
Item No. Unit Description Quantityvials Urine Strips, 10SG 15
boxes Capillary tube heparinized 10 vials/box, chase brand, red top, 8Germany
kit Creatinine, 4 x 50ml., Biochemistry 1vials Blood typing Sera, Anti- A, 1 x 10ml. Diaclon 4vials Blood typing Sera, Anti- B, 1 x 10ml. Diaclon 4
boxes X-ray Film, 11 x 14, 100's Konica 4boxes X-ray Film, 14 x 17, 100's Konica 2box X-ray Fixer, Manual 5 US Gal., Konica 1box X-ray Developer, Manual 5 US Gal. Konica 1
xxxxxxxxxxxxxxxxxxxxxx
A C C E P T A N C E I N S P E C T I O N
Date Received: Date Inspected:
Complete
Partial
Inspection Office/Committee
Property/Supply Officer INSPECTED & VERIFIED BY:
Emma B. Serdon, MD., MPH.,FPCHA EVANGELINA M. ONGHead of Office PAO Representative Provincial Accountant
Noted:ICU Representative
MERCEDES O. PORNELA
Executive Assistant III FELIX L. HABITO
Acting APGDH-PGSO PTO Representative Provincial Treasurer
Inspected, verified and found OK As to quantity and specifications
ANNEX G-7
ACCEPTANCE & INSPECTION REPORTProvincial Government of Quezon
LGU
Supplier Gino's Marketing A / R No.PO No. Date Invoice No. DateRequisitioning Office/Dept. IPHO - QMC
Item No. Unit Description Quantitypcs Toner Copier Model KM -2030, 450g 8
xxxxxxxxxxx
A C C E P T A N C E I N S P E C T I O N
Date Received: Date Inspected:
Complete
Partial
Inspection Office/Committee
Property/Supply Officer INSPECTED & VERIFIED BY:
MERCEDES O. PORNELA EVANGELINA M. ONGHead of Office PAO Representative Provincial Accountant
Noted:ICU Representative
MERCEDES O. PORNELA
Executive Assistant III FELIX L. HABITOActing APGDH-PGSO PTO Representative Provincial Treasurer
Inspected, verified and found OK As to quantity and specifications
Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUEZONLucena city
Request for Quotation
Date:____________
Name of Dealers/Suppliers/Distributor
Business Address
Sir/Madam:
Please quote your lowest government price, taxes included on the following items listed hereunder:
Very truly yours,
ROWELL Q. RADOVANExecutive Assistant/Acting PGSO
End-User of PMO: (PEO/EPOMS)
Approved Budget Contract : P 11,300.00
ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST
1 -1 roll. Roll Steel Tube 3/8 Soft2 -4 pcs. Connector APS3 -1 set Tandem Drive Chain Connector
X-X-X-X-X-X-X-X-X-X-X-X-X-
PROCESSED BY:
Printed Name/Signature
Tel. No./Cellphone No./e-mail address
Date
Quotation No.____________
Name of Program/Project/Activity: Spare Parts for the repair of Motor Grader, MG-09.
Republic of the Philippines
PROVINCE OF QUEZONCity of Lucena
PROVINCIAL GENERAL SERVICES OFFICE
Date
Sir/Madam:
Very truly yours,
EXALTACION Q. ANGELES
PRICE QUOTATION / PRO-FORMA INVOICE
ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST150 pcs. Firefly 18 watts5 pcs. Plastic Globe 12 inches30 pcs. Monggol Socket Adoptor8 pcs. Mercury Bulb 160 watts12 pcs. Receptacle Socket 2 x 2 porcelain
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x
CANVASSED BY:
Dealer
Signature
Please quote your lowest government price, taxes included on the following items listed hereunder:
Republic of the Philippines
PROVINCE OF QUEZONCity of Lucena
PROVINCIAL GENERAL SERVICES OFFICE
Date
Sir/Madam:
Very truly yours,
MERCEDES O. PORNELA
PRICE QUOTATION / PRO-FORMA INVOICE
ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST4 pcs. Headlight socket1 pc. Flasher relay 24 V Electronics
10 pcs. Fuse 30A plug in type
10 pcs. Fuse 20A Plug in type10 pcs. Fuse 15A plug in type
10 pcs. Fuse 10A plug in type
2 pcs. Starter Relay 24V (JIDECO)
2 pcs. Headlight relay 24V
3 pcs. Dimmer Relay 24V1 roll Wire #10 Class A
3 roll Wire #18 Class A
2 roll Wire #16 Class A
1 roll Wire #14 Class A15 pcs. Electrical Tape
10 pcs. Eye terminal 5/16
30 pcs. Eye terminal 3/16
30 pcs. Utilux Wiring socket Female
2 pcs. Bosch relay w/socket 24V
15 mtrs. Wire #12
3 mtrs. Insulator hose #1
7 mtrs. Insulator hose # 1/2
1 roll Soldering Lead
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x--x-x-x-x--x-x-x-x-x-x-x--x-x-x-x-
CANVASSED BY:
Dealer
Signature
Please quote your lowest government price, taxes included on the following items listed hereunder:
Republic of the PhilippinesPROVINCIAL ATTORNEY'S OFFICE
Lucena City
ABSTRACT OF PRICE CANVASSSHOPPING
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 52 (b) of REPUBLIC ACT NO. 9184
Date:(Furnishing and delivery) Time: (a.m./p.m.)(Hauling of materials) Opened:(Furnishing others)
(Public Services, etc.)
JOB ORDER:
1 Replace and fabrication of one (1) pc. HydraulicShaft per instruction as per sample.
2 Hydraulic Cylinder dismantle/cutting of hydrauliccap, to give way for fabrication of new cap,welding build up on cylinder treated portion to giveway for re-treading.
3 Two (2) pcs. Hydraulic Shaft allignment.4 Welding and machining for restoration of
Hydraulic Shaft Packing Seal Head Housing.X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-
For use in the repair of Backhoe Loader BL-01,P.E.O.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXX XXX XXX XXX- - - - - - - - - - - - - - - - - - - - - - - - - - P
(1) that the quotation of the amount
indicated in the above abstract is/are considered as the LOWEST best and the most
advantageous to the government and we therefore recommend that he/they be awarded the corresponding
Purchase Order.
CESARIO T. PALAYAN Romulo M. Edaño, Jr.Requisitioning Officer Provincial Administrator
Chairman BAC
QUOTATION FOR
No. of Item
Description of supplies, materials, equipment, services, etc.
Name of Registered Bidders/Contractors or Dealers
AMOUNT OF BOND (if required)
We hereby certify to the correctness of the above abstract of quotations received and opened in the Provincial Governor's Office.
THE UNDERSIGNED BIDS AND AWARDS COMMITTEE (BAC) FIND:
PROVINCIAL GENERAL SERVICES OFFICELucena City
ABSTRACT OF PRICE CANVASSNEGOTIATED PROCUREMENT
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 53 (h) of REPUBLIC ACT NO. 9184
(Furnishing and delivery) Date:(Hauling of materials) Time: (a.m./p.m.)(Furnishing others) Opened:(Public Service, etc.)
1 unit ALENAIRE PACKAGED TYPE S#HO200914059General cleaning using chemicals & check-up of motor
Replacement of bearing, machinery works & repair of shafting
1 unit ALENAIRE PACKAGED TYPE S#HO200914037General cleaning using chemicals & check-up of motor
Recharging of Freon gas & repair of valve
Replacement of capacitor 50 MFD
Replacement of bearing, machinery works & repair of shafting
1 unit ALENAIRE PACKAGED TYPE S#HO200914071Replacement of capacitor 50 MFD
General cleaning using chemicals & check-up of motor
Complete rewinding of fan motor
1 unit ALENAIRE PACKAGED TYPE General cleaning using chemicals & check-up of motor
Replacement of bearing, machinery works & repair of shafting
1 unit CARRIER WINDOW TYPE
General cleaning using chemicals & check-up of motor
Replacement of capacitor 4 MFD
3 units WINDOW TYPE
General cleaning using chemicals & check-up of motor
1 unit NATIONAL 1.5 HP
General cleaning using chemicals & check-up of motor
Replacement of capacitor 30 MFD
1 unit CARRIER 2 HP
General cleaning using chemicals & check-up of motor
Replacement of capacitor 30 MFD
Replacement of capacitor 7.5 MFD
AMOUNT OF BOND (if required - - - - - - - - - - - - - - - - - - - - - - - - - - P
(1) that the quotation of the amount
indicated in the above abstract is/are considered as the LOWEST best and the most
advantageous to the government and we therefore recommend that he/they be awarded the corresponding
Purchase Order.
EXALTACION Q. ANGELES ARISTEO R. FLORES Requisitioning Officer Provincial Administrator
Chairman BAC
QUOTATION FOR
No. of Item
Description of supplies, materials, equipment, services, etc.
Name of Registered Bidders/Contractors or Dealers
We hereby certify to the correctness of the above abstract of quotations received and opened in the Provincial General Services Office.
THE UNDERSIGNED BIDS AND AWARDS COMMITTEE (BAC) FIND:
PROVINCIAL GENERAL SERVICES OFFICELucena City
ABSTRACT OF PRICE CANVASSNEGOTIATED PROCUREMENT
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 53 (h) of REPUBLIC ACT NO. 9184
Date:Time: (a.m./p.m.)Opened:
150 FOODS MENU: Cheeseburger Softdrinks in Can (Assorted)
xxxxxxxxxxxxxxxxx
AMOUNT OF BOND (if required - - - - - - - - - - - - - - - - - - - - - - - - - - P
(1) that the quotation of POLARIS INDUSTRIAL TRADING CORP. the amount
indicated in the above abstract is/are considered as the LOWEST best and the most
advantageous to the government and we therefore recommend that he/they be awarded the corresponding
Purchase Order.
MERCEDES O. PORNELA ARISTEO R. FLORES Executive Assistant III Provincial Administrator
Acting APGDH-PGSO Chairman BAC
QUOTATION FOR
No. of Item
Description of supplies, materials, equipment, services, etc.
Name of Registered Bidders/Contractors or Dealers
We hereby certify to the correctness of the above abstract of quotations received and opened in the Provincial General Services Office.
THE UNDERSIGNED BIDS AND AWARDS COMMITTEE (BAC) FIND:
Republic of the PhilippinesProvince of Quezon
Lucena City
DISBURSEMENT VOUCHERNo.
Check Cash Others
Payee JAVIMED Pharmaceutical DistributorTIN/Employee No. Obligation Request No.
189-850-810
Address
Responsibility Center Brgy. Bukal Pagbilao Quezon Office/Unit/Project Code
IPHO - QMC
E X P L A N A T I O N AMOUNT
P 618,426.50
TOTAL P 618,426.50A. B. Certified
Allotment obligated for the purpose as indicated above Funds Available
Supporting documents complete
Signature Signature
EVANGELINA M. ONGDate
FELIX L. HABITODate
PositionProvincial Accountant
PositionProvincial Treasurer
Head, Accounting Unit/Authorized Representative Treasurer/Authorized Representative
C. D. Received Payment
Signature Check No.Bank Name Date
RAFAEL P. NANTESDate Signature
Printed Name JAVIMED PHARMECEUTICAL DISTRIBUTOR Date
PositionProvincial Governor OR/Other Documents JEV No. Date
Agency Head/Authorized Representative
JOURNAL ENTRY VOUCHERNo.:
Provincial Government of Quezon Date:
Collection Check Disnursement Cash Disbursement Others
ACCOUNTING ENTRIES
Accounts and Explanation Account Code Ref
Amount
Debit Credit
Prepared by: Approved by:
EVANGELINA M. ONGProvincial Accountant
Mode of Payment
Payment for the purchase of Medicines for use of IPHO - QMC as per supporting papers hereto attached in the total amount of . .
Printed Name
Printed Name
Printed Name
Responsibility
Center