Date of Request:

PMR: Contact No.:

Area:
Nature of Activity: Activity Month: May
Details of the Activity:
Name of Entity/Venue: Municipality & Province:

Participants in the Activity: Estimated Total Number:      

Pediatrics: OB-Gyne:       FM GEN:
GPs: IM:       Nurses:
Midwives: Nutritionists:       BHWs/BNS:

Expenses to be Incurred:
Expense Estimated Cost
AM Snacks      
PM Snacks 9,600.00
Lunch      
Others (please specify)      
Total Estimated Expenses: 9,600.00 Php

Budget Charging: Product Presentation

Previous Balance: ____________________________
New Balance: _______________________________

Submitted by: Approved by: Noted by:

(Printed Name & Signature) (Printed Name & Signature) (Printed Name & Signature)
Professional Medical Representative Professional Medical Supervisor Business Unit Manager
Contact #: Contact #: Contact #:
Attachments: List of HCPs

This interaction with Healthcare Professionals solely serves to promote Continuing Medical Education and is consistent with
the   implementation   of   the   WHO   Code   on   Marketing   of   Breastmilk   Substitutes   and   will   not   in   any   way   be   linked   to   the
prescription of products within the scope of the WHO Milk Code, EO 51 and its RIRR.
List of HCPs:
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