Standard Form Number: SF-GOOD-63

Standard Form Number: SF-GOOD-63

Standard Form Title: Agency Procurement RequestNAME AND ADDRESS AGENCY

OF REQUESTING ACCT. CODE

AGENCY AGENCY CONTROL No.

AGENCY PROCUREMENT REQUEST PS APR No.

To: THE PROCUREMENT SERVICE

DBM Compound, RR Road

Cristobal St., Paco Manila

(Date Prepared)

ACTION REQUESTED ON THE ITEM LISTED BELOW

[ ] Please furnish us with the Price Estimate (for office equipment/furniture & supplementary items)

[ ] Please purchase for our agency the equipment/furniture/supplementary items per your Price Estimate

(PS RAD No. _____________________attached) dated__________________, _______

[ ] Please issue common-use supplies/materials per price list as of ____________________, _______

[ ] Please issue certificate or Price Reasonableness

[ ] Please furnish us with your latest/updated Price List

[ ] Others (Specify)_______________________________________________________________________________________

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

ITEMITEM AND DESCRIPTION SPECIFICATIONS/STOCK No.QUANTITYUNITUNIT PRICEAMOUNT

NO.

Total AMOUNT P

NOTE: ALL SIGNATURES MUST BE OVER PRINTED NAME

STOCK REQUESTED ARE CERTIFIED TO BE

WITHIN APPROVED PROGRAM:

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AGENCY PROPERTY SUPPLY OFFICERFUNDS CERTIFIED AVAILABLE:

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AGENCY CHIEF ACCOUNTANTAPPROVED:

-----------------------------------------------AGENCY HEAD/AUTHORIZED SIGNATURE

[ ] FUND DEPOSITE WITH PS [ ] _________________ CHECK No. ____________________

IN THE AMOUNT OF: ____________________________________________________________ (P ) ENCLOED