Republic of the Philippines

Department of Education
Region VI – Western Visayas
Division of Roxas City
Roxas City District I
DUMOLOG NATIONAL HIGH SCHOOL
SENIOR HIGH SCHOOL
City of Roxas

SCIENCE LABORATORY REQUEST FORM

Subject: ____________________________________________________________________________________
Date of Use Time Grade & Section

Purpose: ____________________________________________________________________________________
Place of Use: _________________________________________________________________________________

Apparatus, Equipment & Non-consumable/Non-disposal Supplies (pls. be specific):

Remarks
Quantity Description (To be filled out by lab. In-charge)
As Released As Returned

Chemicals & Other Consumable/Disposable Supplies (pls. be specific):

Quantity Description Remarks

Requested by: Noted by (if the requesting body is a student:

____________________________ ____________________________________
Requesting Body Subject Teacher

Approved by:

____________________________________
Laboratory-in-Charge