Name of the Procuring Entity Project Reference Number

Name of the Project

Standard Form Number: SF-GOOD-59 Location of the Project
Revised on: May 24, 2004
Standard Form Title: Purchase Request

PURCHASE REQUEST

Municipality of Jomalig
Agency/Procuring Entity

Department: ______________________ PR No. ________________ Date: __________________

Section: ______________________ SAI No. ________________ Date: _________________

STOCK Unit of Item Estimated Estimated

Quantity
NO. Issue Description Unit Cost Cost
1 Pcs Brother LC 539 XL-BK 5 390.00 1,950.00
2 Pcs Brother LC 535XL-Y 3 390.00 1,170.00
3 Pcs Brother LC 535XL-M 3 390.00 1,170.00
4 Pcs Brother LC 535XL-C 3 390.00 1,170.00
5 Box Sign pen (5) 2 33.64 67.28
6 Pcs Record Book 500 pp 2 86.36 172.72
7 Reams Bond Paper (Long) 10 197.27 1,972.70
8 Reams Bond Paper (Short) 10 168.18 1,681.80
9 Box Ballpen Black 3 343.64 1,030.92
10 Rolls Tissue Paper 3 20.91 62.73
11 Pcs Folder (Long) 20 5.68 113.60
12 Pcs Folder (Short) 20 4.82 96.40
13 Box Pencil 1 90.91 90.91
14 Pcs Scotch Tape (1x90B) 2 22.73 45.46
15 Box Staple Wire #35 1 50.91 50.91
16 Box Staple Wire #10 3 10.00 30.00
17 Box Plastic Fastener 1 41.36 41.36
18 Box Permanent Marker 5 47.27 236.35
19 Pcs Cartolina 20 7.00 140.00
20 Pcs Manila Paper 20 5.00 100.00
21 Pcs Correction Tape 10 41.36 413.60
22 Pcs Stabilo Re-liner 10 10.50 105.00
23 Pc Glue 130g 1 90.91 90.91
24 Pc Zonrox 1 50.00 50.00
25 pc Hand Wash 1 60.00 60.00
26 btl Detergent Powder 6 6.00 36.00
27 pc Scotch Brite 2 35.00 70.00

TOTAL 12,218.65
Purpose/Remarks Used in the Office of the Sangguniang Bayan

Requested by: Approved by:

Signature
Printed Name: MARY ANN S. PIOPONGCO DAHLIA T. MANALO
Designation SB Secretary Municipal Vice Mayor
 Republic of the Philippines
MUNICIPALITY OF JOMALIG
Province of Quezon
PURCHASE ORDER
Supplier: P.O No.
Address: Jomalig Quezon Date:
_______________________________________________________ Mode of Procurement
Gentlemen:
Please furnish this office the following articles subject to the terms and condition
contained herein:
Place of Delivery:
Date of Delivery:
Item No. Unit Quantity Discription Unit Cost Amount
1 3 Pcs Brother LC 539 XL-BK 390.00 1,170.00
2 2 Pcs Brother LC 535XL-Y 390.00 780.00
3 2 Pcs Brother LC 535XL-M 390.00 780.00
4 2 Pcs Brother LC 535XL-C 390.00 780.00
5 2 Box Sign pen (5) 33.64 67.28
6 1 Pc Record Book 500 pp 86.36 86.36
7 6 Reams Bond Paper (Long) 197.27 1,183.62
8 5 Reams Bond Paper (Short) 168.18 840.90
9 3 Box Ballpen Black 343.64 1,030.92
10 3 Rolls Tissue Paper 20.91 62.73
11 12 Pcs Folder (Short) 5.68 68.16
12 12 Pcs Folder (Long) 4.82 57.84
13 1 Box Pencil 90.91 90.91
14 2 Pcs Scotch Tape (1x90B) 22.73 45.46
15 1 Box Staple Wire #35 50.91 50.91
16 3 Box Staple Wire #10 10.00 30.00
17 1 Box Plastic Fastener 41.36 41.36
18 5 Box Permanent Marker 47.27 236.35

TOTAL 7,402.80
Conforme: Very Truly Yours
_________________________________
(Signature Over Printed Name) DAHLIA T. MANALO
_______________ Municipal Vice Mayor
Date
(In case of negotiated Purchaed pursuant to Sec. 369(a) of RA 7160. This Portion must be accomplished)
Approved per sanggunian Res. No.__________________________
Certified Correct:
_______________________________________ ____________
 Republic of the Philippines
MUNICIPALITY OF JOMALIG
Province of Quezon

PURCHASE REQUEST

Department: OFFICE OF THE SANGGUNIANG BAYAN DATE:

Section:
Item Unit of Item Estimated Estimated
Quantity
No. Issue Discription Unit Cost Cost
1 2 reams Bond Paper Long
2 12 pcs. Folder Long
3 2 pad RER
4 12 pcs. Ballpen
5 2 pcs. Sign Pen

TOTAL:

Purpose: used in the office of the Sangguniang Bayan.

Requested by: Approved by:

Signature
Printed Name MARY ANN S. PIOPONGCO DAHLIA T. MANALO
Designation SB SECRETARY Mun. Vice Mayor
 Republic of the Philippines
MUNICIPALITY OF JOMALIG
Province of Quezon
PURCHASE ORDER
Supplier: P.O No.
Address: Date:
_______________________________________________________ Mode of Procurement
Gentlemen:
Please furnish this office the following articles subject to the terms and condition contained herein:
Place of Delivery:
Date of Delivery:

Item No. Unit Quantity Discription Unit Cost Amount

1 reams 2 Bond Paper Long
2 pcs. 12 Folder Long
3 pad 2 RER
4 pcs. 12 Ballpen
5 pcs. 5 Sign Pen

Total
Conforme: Very Truly Yours

(Signature Over Printed Name) DAHLIA T. MANALO

Municipal Vice Mayor
Date
(In case of negotiated Purchaed pursuant to Sec. 369(a) of RA 7160. This Portion must be accomplished)
Approved per sanggunian Res. No.__________________________
Certified Correct:
 Republic of the Philippines
MUNICIPALITY OF JOMALIG
Province of Quezon
PURCHASE ORDER
Supplier: MICRO VALLEY, PACIFIC MALL P.O No.
Address: LUCENA CITY Date:
_______________________________________________________ Mode of Procurement
Gentlemen:
Please furnish this office the following articles subject to the terms and condition contained herein:
Place of Delivery:
Date of Delivery:

Item No. Unit Quantity Discription Unit Cost Amount

1 pc 1 Ink Brother Innobella LC539XL-BK

Total
Conforme: Very Truly Yours

(Signature Over Printed Name) DAHLIA T. MANALO

Municipal Vice Mayor
Date
(In case of negotiated Purchaed pursuant to Sec. 369(a) of RA 7160. This Portion must be accomplished)
Approved per sanggunian Res. No.__________________________
Certified Correct:
 Republic of the Philippines
MUNICIPALITY OF JOMALIG
Province of Quezon

PURCHASE REQUEST

Department: OFFICE OF THE SANGGUNIANG BAYAN DATE:

Section:
Item Unit of Item Estimated Estimated
Quantity
No. Issue Discription Unit Cost Cost

1 1 pc Brother (LC539XL-BK)

TOTAL:

Purpose: used in the office of the Sangguniang Bayan.

Requested by: Approved by:

Signature
Printed Name MARY ANN S. PIOPONGCO DAHLIA T. MANALO
Designation SB SECRETARY Mun. Vice Mayor