Page 1 of 4

NAME AND ADDRESS AGENCY

OF REQUESTING ACCT. CODE
AGENCY AGENCY CONTROL No.
AGENCY PROCUREMENT REQUEST PS APR No.
To: THE PROCUREMENT SERVICE
DBM - Region I
Gov't Center, Sevilla Center (Date Prepar
San Fernando City, La Union

PLEASE CHECK ( / ) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM LISTED BELOW

[ ] Please issue common-use supplies/materials per Price List No. _____________________ dated _______________________
Mode of Delivery : [ ] Pick-up (Fast Lane) [ ] Pick-up schedule [ ] Delivery (door-to-door)

In case fund is not sufficient :[ ] Reduce Quantity [ ] Bill Us [ ] Charged to Unutilized Deposit, APR No. __________ Dated: ______________

[ ] Please purchase for our agency non-common items. Attached herewith:

[ ] Complete Specifications [ ] Obligation Request (ObR) [ ] Others, pls. specify ___________
[ ] Certificate of Budget Allocation (CBA) [ ] Payment ___________________________

IMPORTANT!! PLEASE SEE THE INSTRUCTIONS/CONDITIONS AT THE BACK OF ORIGINAL COPY

ITEM NO. ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK NO. QUANTITY UNIT

Total AMOUN
NOTE : ALL SIGNATURES MUST BE OVER PRINTED NAME
STOCKS REQUESTED ARE CERTIFIED TO BE FUNDS CERTIFIED AVAILABLE: APPROVED:
WITHIN APPROVED PROGRAM:

AGENCY PROPERTY SUPPLY OFFICER AGENCY CHIEF ACCOUNTANT AGENCY HEAD/AUTHORIZED

 Page 2 of 4

NAME AND ADDRESS AGENCY

OF REQUESTING ACCT. CODE
AGENCY AGENCY CONTROL No.
AGENCY PROCUREMENT REQUEST PS APR No.
To: THE PROCUREMENT SERVICE
DBM - Region I
Gov't Center, Sevilla Center (Date Prepar
San Fernando City, La Union

PLEASE CHECK ( / ) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM LISTED BELOW

[ ] Please issue common-use supplies/materials per Price List No. _____________________ dated _______________________
Mode of Delivery : [ ] Pick-up (Fast Lane) [ ] Pick-up schedule [ ] Delivery (door-to-door)

In case fund is not sufficient :[ ] Reduce Quantity [ ] Bill Us [ ] Charged to Unutilized Deposit, APR No. __________ Dated: ______________

[ ] Please purchase for our agency non-common items. Attached herewith:

[ ] Complete Specifications [ ] Obligation Request (ObR) [ ] Others, pls. specify ___________
[ ] Certificate of Budget Allocation (CBA) [ ] Payment ___________________________

IMPORTANT!! PLEASE SEE THE INSTRUCTIONS/CONDITIONS AT THE BACK OF ORIGINAL COPY

ITEM NO. ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK NO. QUANTITY UNIT

[ ] FUNDS DEPOSITED WITH PS [ ] _________________ CHECK No. ______________

IN THE AMOUNT OF ___________________________________________ (P _______________) ENCLOSED
 Page 3 of 4

AGENCY CONTROL No. 0

(Date Prepared)

BOX ON ACTION REQUESTED ON THE ITEM LISTED BELOW

Others, pls. specify ________________

________________________________

TRUCTIONS/CONDITIONS AT THE BACK OF ORIGINAL COPY

Unit Price AMOUNT

Total AMOUNT 0.00

NATURES MUST BE OVER PRINTED NAME

AGENCY HEAD/AUTHORIZED SIGNATURE

 Page 4 of 4

AGENCY CONTROL No. 0

(Date Prepared)

BOX ON ACTION REQUESTED ON THE ITEM LISTED BELOW

Others, pls. specify ________________

________________________________

TRUCTIONS/CONDITIONS AT THE BACK OF ORIGINAL COPY

Unit Price AMOUNT