Canvass Form Blank

Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION

National Capital Region & Rizal Group
10th Flr. Sunnymede I.T Center Bldg., 1614 Brgy South Triangle, Quezon Ave., Quezon City
E - Mail: procurement.proncr@yahoo.com
Telefax: 441-2579
DATE
CANVASS QUOTATION
Please furnish us with your lowest quotations for the following items & submit the same in a
sealed envelope or fax to the Head, Procurement Section on or before :
NO.
QTY
UNIT
ITEM DESCRIPTION
112
UNITS
DRUM KIT, FOR FUJI XEROX DOCUPRINT P455

MONOCHROME LASER PRINTER
708
CA
TONER CARTRIDGE, FOR FUJI XEROX DOCUPRINT

P455 MONOCHROME LASER PRINTER
2)
UNIT
AMOUNT
TOTAL AMOUNT
*** Please fax or e-mail a copy of the following documents:

a. BIR Registration - 2303
b. DTI / SEC Registration
c. 3 months Philhealth Contributions Receipt (Ocotber- December 2015)
d. Business Permit / Mayor's Permit 2016
e. 0605- Payment Form 2016
f. Updated Philgeps Registration
Very truly yours,
MARK ANGELO PATERO

Official Canvasser
TO: PHILIPPINE HEALTH INSURANCE CORPORATION
ATTENTION: DIODE G. LANTORIA
Ma'am:
I/We bind myself/ourselves that the above items quoted price(s) is/are final per your
specifications and/or sample and is/are available only within the period from
Delivery Period:
Terms of payment:
Business Name & Address:
(Printed Name & Signature of
Authorized Representative)
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 1 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
86
REAM
S
PRE-PRINTED CERTIFICATE FOR MEMBERSHIP

REGISTRATION
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 2 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
165
CA
TONER CA, FOR BROTHER FAX MACHINE MODEL:

MFC-7360/MFC-7290/2840_
32
UNIT
DRUM KIT, FOR BROTHER FAX MACHINE, MODE:

MFC-7360/MFC-7290/2840
124
CA
TONER CA, FOR BROTHER MAX MACHINE, MODEL:

MFC-L2700D, TN2380, HIGH CAPACITY
16
UNIT
DRUM KIT, FOR BROTHER FAX MACHINE, MODEL:

L2700, DR2355
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 3 of 21
Page 4 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
69
BOXE
S
UTP CABLE, CAT6E
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 5 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
922
Pcs
CORRECTION TAPE, With dispenser, 5mm x 10m
1191
Pcs
DATA FOLDER, With finger ring and clear plastic pocket

for labels, 76mm x 229mm x 381mm (3' x 9' 15')
2)
UNIT
AMOUNT
TOTAL AMOUNT

c. 3 months Philhealth Contributions Receipt (Jan - Mar, 2016)
Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 6 of 21
Page 7 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
35
CA
INK E TYPE BLACK FOR RISO EZ 221A
ROLL
MASTER RZ A4 FOR RISO EZ 221A
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 8 of 21
Page 9 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
112
CA
INK FOR DUPLO DUPLICATOR MODEL DPL-520
47
ROLL
2)
UNIT
AMOUNT
TOTAL AMOUNT
MASTER ROLL FOR DUPLO DUPLICATOR MODEL

DPL-520

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 10 of 21
Page 11 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
52
CA
INK CARTRIDGE, For Pitney Bowes Mailing/Metering

Machine, Fluorescent Red DM300c/DM400c, 45ml (Part
No. 765-9)
Units
PRINT HEAD, For Pitney Bowes Metering Machine, Part

No. 4G8-0024
Boxes
E-Z SEAL, For Pitney Bowes Metering Machine, 4/box,

Part No. 601-0
Units
INK WASTE PAD, For Pitney Bowes Metering Machine,

Part No. 625-0
Pack
ADHESIVE TAPE, For Pitney Bowes Metering Machine,

200pcs/pack
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
Page 12 of 21
E-mail Add :
(Designation)
Page 13 of 21
Page 14 of 21
Page 15 of 21

Tel : 709-7046
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
LOT
NEWSPAPER SUBSCRIPTION
(1 YEAR)
UNIT
AMOUNT
TOTAL AMOUNT
Very truly yours,
CHARLENE AGOJO

ATTENTION: RONALD M. VERGARA
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 16 of 21
Page 17 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
UNIT
DRUM KIT, For Network Printer, Model: Phaser 4600

(DrumKit)
26
CA
TONER CARTRIDGE, For FUJI Xerox Phaser 4600DN
2)
UNIT
AMOUNT
TOTAL AMOUNT

Very truly yours,
MARK ANGELO PATERO

Official Canvasser
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 18 of 21
Page 19 of 21

Telefax: 441-2579
DATE
CANVASS QUOTATION
NO.
QTY
UNIT
ITEM DESCRIPTION
UNIT
AMOUNT
TOTAL AMOUNT
2)

Very truly yours,
Canvasser
ATTENTION:
Ma'am:
Delivery Period:
Terms of payment:
Tel. / Fax No. :
E-mail Add :
(Designation)
Page 20 of 21
Page 21 of 21

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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

DRUM KIT, FOR FUJI XEROX DOCUPRINT P455

TONER CARTRIDGE, FOR FUJI XEROX DOCUPRINT

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

PRE-PRINTED CERTIFICATE FOR MEMBERSHIP

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

TONER CA, FOR BROTHER FAX MACHINE MODEL:

DRUM KIT, FOR BROTHER FAX MACHINE, MODE:

TONER CA, FOR BROTHER MAX MACHINE, MODEL:

DRUM KIT, FOR BROTHER FAX MACHINE, MODEL:

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

UTP CABLE, CAT6E

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

CORRECTION TAPE, With dispenser, 5mm x 10m

DATA FOLDER, With finger ring and clear plastic pocket

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

INK E TYPE BLACK FOR RISO EZ 221A

MASTER RZ A4 FOR RISO EZ 221A

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

INK FOR DUPLO DUPLICATOR MODEL DPL-520

MASTER ROLL FOR DUPLO DUPLICATOR MODEL

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

INK CARTRIDGE, For Pitney Bowes Mailing/Metering

PRINT HEAD, For Pitney Bowes Metering Machine, Part

E-Z SEAL, For Pitney Bowes Metering Machine, 4/box,

INK WASTE PAD, For Pitney Bowes Metering Machine,

ADHESIVE TAPE, For Pitney Bowes Metering Machine,

*** Please fax or e-mail a copy of the following documents:

Very truly yours,

MARK ANGELO PATERO

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Very truly yours,

TO: PHILIPPINE HEALTH INSURANCE CORPORATION