Abstract Form (Bl-01)

Annex A
Republic of the Philippines

Province of Quezon
Lucena City
No.
OBLIGATION REQUEST
Payee GODWIN LADLAD, ET AL.
Office PROVINCIAL ENGINEER'S OFFICE
Address Brgy. Talipan, Pagbilao, Quezon
Responsibility Account
Particulars F. P. P. Amount
Center Code
PER DIEM Php 15,000.00

Godwin Ladlad - Php 5,440.00
Lysander Ladlad - Php 2,300.00
Edwin Matienzo - Php 1,920.00
Ricardo Gollena - Php 2,620.00
Fernando Llaneta - Php 2,720.00
TOTAL Php 15,000.00
TOTAL Php 15,000.00

A. Certified B. Certified
Charges to appropriation/allotment necessary, lawful Existence of available appropriation
and under my direct supervision
Supporting documents valid, proper and legal
Signature Signature
Printed Name CESARIO T. PALAYAN Printed Name GODOFREDO E. MATIENZO

Provincial Engineer Provincial Budget Officer
Position Position
Head, Requesting Office/Authorized Representative Head, Budget Unit/Autorized Representative
Date Date
Standard Form No: SF-GOOD-58
Revised on: May 24, 2004
PURCHASE ORDER
Province of Quezon
LGU
SUPPLIER : MAVIL PETRON SERVICE CENTER P.O. NO. :

Address : Diversion Road, Silangang Mayao, Lucena City DATE :
E-Mail Address : Mode of Procurement:
Telephone No. : PR No./s :
TIN :
Gentlemen:
Please furnish this office the following articles subject to the terms and conditions contained herein:
Place of Delivery : Delivery Term :
Date of Delivery: Payment Term :
Stock
No.
Unit. Qty. Description Unit Cost Total Cost
PR. NO.
March 17-21, 2008
Liters 60 Diesel P 38.69 P 2, 321.40
Liter 1 Brake Fluid 277.00 277.00
Pail 1 Oil #10 1, 879.00 1, 879.00
March 22-28, 2008
Liters 444 Diesel 39.19 16, 851.70
Liters 14 XCS Gasoline 46.96 657.44
March 29-Aapril 7, 2008
Liters 315 Diesel 39.69 12, 281.70
April 8, 2008
Liters 430 Diesel 40.19 17, 281.70
Pc 1 Brake Fluid (250 ml) 88.00 88.00
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Fifty one thousand eight hundred fifty eight pesos & fifty nine centavos only P P 51, 858.59
(Total Amount in Words)
In case of failure to make the full delivery within the time specified above, a penalty of one-tenth (1/10)
of one percent for every day of delay shall be imposed.
Approved:
RAFAEL P. NANTES
Conforme: Governor
MONICO VILLANUEVA
(Signature over Printed Name)
(Date)
Obligation of Allotment : Funds Available
EVANGELINA M. ONG FELIX L. HABITO

Provincial Accountant Provincial Treasurer
Amount : _______________
Allotment No.: ___________
Standard Form Title: Purchase Request
PURCHASE REQUEST
PROVINCIAL GOVERNMENT OF QUEZON

Agency / Procuring Entity
Department Provincial General Services Office PR No Date:

Section SAI No Date:
Stock No. Unit Item Description QTY. Unit Cost Total Cost
rms Copy Paper Short 100 275.00 27,500.00

rms Copy Paper Long 100 285.00 28,500.00
bxs Ballpen Blue 2 275.00 550.00
pcs Folders Long 300 4.50 1,350.00
ink Cartridge Ink for HP 21 3 1,200.00 3,600.00
ink Cartridge Ink for HP 15A 1 3,950.00 3,950.00
packs Laid Board Short 30 38.00 1,140.00
box Pentel Pen 1 540.00 540.00
pcs Record Book 5 65.00 325.00
bxs Sign Pen / High Tech Pen 1.5 3 260.00 780.00
tube Toner - Xerox Machine 2 4,500.00 9,000.00
xxxxxxxxxxxxxx 108,185.00
P 108,185.00
Purpose / Remarks: For use in the office of the Provincial General Services
Requested by: Approved by:

Signature:
Printed Name: MERCEDES O. PORNELA RAFAEL P. NANTES
Designation Executive Assistant III / Acting APGDH - PGSO Provincial Governor
Date:
PURCHASE REQUEST

Department Janitorial Services - PGSO PR No Date:

bot Air fresherner 12 245.00 2,940.00
bot Alcohol 12 68.00 816.00
bot Cleanser, big 15 45.00 675.00
bot Dish Washing Liquid, Joy 15 68.00 1,020.00
cans Disinfectant Spray, Baygon 15 275.00 4,125.00
cans Insecticide 12 285.00 3,420.00
kilo Powder Soap 6 165.00 990.00
gal Muriatic Acid 10 145.00 1,450.00
pcs Toilet Deodorant 15 43.00 645.00
packs Tissue Paper , 2 ply Joy 12 180.00 2,160.00
pcs Trash Bag 200 7.00 1,400.00
pcs Brown Tambo 12 95.00 1,140.00
pcs Brown Tingting 50 18.00 900.00
pcs Dust Pan 12 65.00 780.00
pcs Mop Handle - Screw Type 10 275.00 2,750.00
pcs Mop Head - all cotton 20 55.00 1,100.00
pcs Plastic Pail 10 85.00 850.00
pcs Rag 15 45.00 675.00
pcs Scouring Pad 12 65.00 780.00
doz Soap 2 420.00 840.00
pcs Tabo 10 20.00 200.00
pcs Toilet Bowl Brush 14 35.00 490.00
pcs Door Knob 3 385.00 1,155.00
packet Battery - Size AA 5 37.10 185.50
pcs Padlock 10 120.00 1,200.00
TOTAL P 32,686.50
Purpose / Remarks: FOR USE IN THE OFFICE OF THE PROVINCIAL GENERAL SERVICES
Signature:
Date:
PURCHASE REQUEST

Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:

bot Air freshener 12 245.00 2,940.00
bot Alcohol 12 68.00 816.00
bot Cleanser, big 15 45.00 675.00
bot Dish Washing Liquid, Joy 15 68.00 1,020.00
cans Disinfectant Spray, Baygon 15 275.00 4,125.00
cans Insecticide 12 285.00 3,420.00
kilo Powder Soap 6 165.00 990.00
gal Muriatic Acid 10 145.00 1,450.00
pcs Toilet Deodorant 15 43.00 645.00
packs Tissue Paper , 2 ply Joy 12 180.00 2,160.00
pcs Trash Bag 200 7.00 1,400.00
pcs Broom Tambo 12 95.00 1,140.00
pcs Broom Tingting 50 18.00 900.00
pcs Dust Pan 12 65.00 780.00
pcs Mop Handle - Screw Type 10 275.00 2,750.00
pcs Mop Head - all cotton 20 55.00 1,100.00
pcs Plastic Pail 10 85.00 850.00
pcs Rag 15 45.00 675.00
pcs Scouring Pad 12 65.00 780.00
doz Soap 2 420.00 840.00
pcs Dipper 10 20.00 200.00
pcs Toilet Bowl Brush 14 35.00 490.00
pcs Door Knob 3 385.00 1,155.00
packs Battery - Size AA 5 37.10 185.50
pcs Padlock - Heavy Duty 10 120.00 1,200.00
TOTAL P 32,686.50
Purpose / Remarks: FOR USE IN THE OFFICE OF THE PROVINCIAL GENERAL SERVICES

Signature:
Date:
PURCHASE REQUEST
Department Provincial Engineer's Office PR No Date:

March 17-21, 2008
Liters Diesel 60 P 38.69 P 2, 321.40
Liter Brake Fluid 1 277.00 277.00
Pail Oil #10 1 1,879.00 1,879.00
March 22-28, 2008
Liters Diesel 444 39.19 16,851.70
Liters XCS Gasoline 14 46.96 657.44
Liters Diesel 315 39.69 12,502.35
April 8, 2008
Liters Diesel 430 40.19 17,281.70
Pc Brake Fluid (250 ml) 1 88.00 88.00
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
TOTAL P 51, 858.59
Purpose / Remarks: For use in Equipment Pool Operations & Management Services

Signature:
Printed Name: RAFAEL P. NANTES RAFAEL P. NANTES
Designation Provincial Governor Provincial Governor

Date:
PURCHASE REQUEST
Provincial Government of Quezon


pcs. Philippine Flag 7' x 13' 8 3,800.00 30,400.00
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-
TOTAL P 30,400.00
Purpose / Remarks: FOR USE AT PEREZ PARK

Signature:
Printed Name: RAFAEL P. NANTES
MERCEDES O. PORNELA
Executive Assistant III
Designation Provincial Governor
Acting APGDH-PGSO
Date:
PURCHASE REQUEST

11/5/2007 ltrs. Petron Diesel ### 1,000.00
11/9/2007 ltrs. Shell Diesel 51.54 1,878.63
11/14/2007 ltrs. Shell Diesoline 40.11 1,492.10
11/16/2007 Body Wash, Vacuum 100.00
11/19/2007 ltrs. Shell Diesel ### 1,667.05
11/21/2007 Body Wash 50.00
Vacuum 50.00
Setting 120.00
Carpet Shampoo 120.00
Wax 100.00
11/23-24/07 ltrs. Petron Diesel ### 1,500.00
11/27/2007 ltrs. Shell Diesoline ### 1,322.46
11/29/2007 ltrs. Petron Diesel ### 1,869.30
Parking & Toll Fees 772.00
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-
TOTAL P 12,041.54
Purpose / Remarks: FOR USE OF SFN-303 ASSIGNED TO THE PROVINCIAL GENERAL

SERVICES OFFICER.

Signature:
Printed Name: EXALTACION Q. ANGELES RAFAEL P. NANTES
Designation Provincial General Services Officer Provincial Governor
Date:
ACCEPTANCE & INSPECTION REPORT
LGU
Supplier A / R No.
PO No. Date Invoice No. Date
Requisitioning Office/Dept.
Item No. Unit Description Quantity

March 17-21, 2008
Liters Diesel 60
Liter Brake Fluid 1
Pail Oil #10 1
March 22-28, 2008
Liters Diesel 444
Liters XCS Gasoline 14
Liters Diesel 315
April 8, 2008
Liters Diesel 430
Pc Brake Fluid (250 ml) 1
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Date Received: Date Inspected:
XXXXXXXX Complete Inspected, verified and found OK As

to quantity and specifications
Partial
Inspection Office/Committee
REO-AMBROSIO MAAÑO III
Asst. Provincial Engineer - EPOMS INSPECTED & VERIFIED BY:
OIC
CESARIO T. PALAYAN EVANGELINA M. ONG

Head of Office PAO Representative Provincial Accountant
Noted:
ICU Representative
MERCEDES O. PORNELA
C FELIX L. HABITO
Acting APGDH-PGSO PTO Representative Provincial Treasurer
ANNEX G-7

LGU
Supplier Gino's Marketing A / R No.

Requisitioning Office/Dept. MMDH-LOPEZ

vials Urine Strips, 10SG 15
boxes Capillary tube heparinized 10 vials/box, chase brand, red top, 8
Germany
kit Creatinine, 4 x 50ml., Biochemistry 1
vials Blood typing Sera, Anti- A, 1 x 10ml. Diaclon 4
vials Blood typing Sera, Anti- B, 1 x 10ml. Diaclon 4
boxes X-ray Film, 11 x 14, 100's Konica 4
boxes X-ray Film, 14 x 17, 100's Konica 2
box X-ray Fixer, Manual 5 US Gal., Konica 1
box X-ray Developer, Manual 5 US Gal. Konica 1
xxxxxxxxxxxxxxxxxxxxxx
ACCEPTANCE INSPECTION
Complete
Inspected, verified and found OK As
Partial
Property/Supply Officer INSPECTED & VERIFIED BY:
Emma B. Serdon, MD., MPH.,FPCHA EVANGELINA M. ONG

Noted:
ICU Representative
MERCEDES O. PORNELA
Executive Assistant III FELIX L. HABITO

ANNEX G-7

LGU
Supplier Gino's Marketing A / R No.

Requisitioning Office/Dept. IPHO - QMC

pcs Toner Copier Model KM -2030, 450g 8
xxxxxxxxxxx
ACCEPTANCE INSPECTION
Complete
Inspected, verified and found OK As
Partial
Property/Supply Officer INSPECTED & VERIFIED BY:
MERCEDES O. PORNELA EVANGELINA M. ONG

Noted:
ICU Representative
MERCEDES O. PORNELA
Executive Assistant III FELIX L. HABITO
Lucena city
Request for Quotation
Date:____________
Quotation No.____________
Name of Dealers/Suppliers/Distributor
Business Address
Sir/Madam:
Please quote your lowest government price, taxes included on the following items listed hereunder:
Very truly yours,
ROWELL Q. RADOVAN
Executive Assistant/Acting PGSO
Name of Program/Project/Activity: Spare Parts for the repair of Motor Grader, MG-09.
End-User of PMO: (PEO/EPOMS)
Approved Budget Contract : P 11,300.00
ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST

1 -1 roll. Roll Steel Tube 3/8 Soft
2 -4 pcs. Connector APS
3 -1 set Tandem Drive Chain Connector
X-X-X-X-X-X-X-X-X-X-X-X-X-
PROCESSED BY:
Printed Name/Signature
Tel. No./Cellphone No./e-mail address
Date
PROVINCE OF QUEZON
City of Lucena
PROVINCIAL GENERAL SERVICES OFFICE
Date
Sir/Madam:
Please quote your lowest government price, taxes included on the following items listed
hereunder:
Very truly yours,
EXALTACION Q. ANGELES
PRICE QUOTATION / PRO-FORMA INVOICE

150 pcs. Firefly 18 watts
5 pcs. Plastic Globe 12 inches
30 pcs. Monggol Socket Adoptor
8 pcs. Mercury Bulb 160 watts
12 pcs. Receptacle Socket 2 x 2 porcelain
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x
CANVASSED BY:
Dealer
Signature
PROVINCE OF QUEZON
City of Lucena
Date
Sir/Madam:
Please quote your lowest government price, taxes included on the following items listed
hereunder:
Very truly yours,
MERCEDES O. PORNELA
PRICE QUOTATION / PRO-FORMA INVOICE

4 pcs. Headlight socket
1 pc. Flasher relay 24 V Electronics
10 pcs. Fuse 30A plug in type
10 pcs. Fuse 20A Plug in type
2 pcs. Starter Relay 24V (JIDECO)
2 pcs. Headlight relay 24V
3 pcs. Dimmer Relay 24V
1 roll Wire #10 Class A
15 pcs. Electrical Tape
10 pcs. Eye terminal 5/16
30 pcs. Eye terminal 3/16
30 pcs. Utilux Wiring socket Female
2 pcs. Bosch relay w/socket 24V
15 mtrs. Wire #12
3 mtrs. Insulator hose #1
7 mtrs. Insulator hose # 1/2
1 roll Soldering Lead
x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x--x-x-x-x--x-x-x-x-x-x-x--x-x-x-x-
CANVASSED BY:
Dealer
Signature
PROVINCIAL ATTORNEY'S OFFICE
Lucena City
ABSTRACT OF PRICE CANVASS
SHOPPING
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 52 (b) of REPUBLIC ACT NO. 9184
Date:
QUOTATION (Furnishing and delivery) Time: (a.m./p.m.)
FOR (Hauling of materials) Opened:
(Furnishing others)
(Public Services, etc.)
No. of Description of supplies, materials, equipment, Name of Registered

Item services, etc. Bidders/Contractors or Dealers
JOB ORDER:
1 Replace and fabrication of one (1) pc. Hydraulic

Shaft per instruction as per sample.
2 Hydraulic Cylinder dismantle/cutting of hydraulic
cap, to give way for fabrication of new cap,
welding build up on cylinder treated portion to give
way for re-treading.
3 Two (2) pcs. Hydraulic Shaft allignment.
4 Welding and machining for restoration of
Hydraulic Shaft Packing Seal Head Housing.
X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-
For use in the repair of Backhoe Loader BL-01,
P.E.O.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXX XXX XXX XXX

AMOUNT OF BOND (if required) -------------------------- P
We hereby certify to the correctness of the above abstract of quotations received and opened in the Provincial
Governor's Office.
THE UNDERSIGNED BIDS AND AWARDS COMMITTEE (BAC) FIND:
(1) that the quotation of the amount

indicated in the above abstract is/are considered as the LOWEST best and the most
advantageous to the government and we therefore recommend that he/they be awarded the corresponding
Purchase Order.
CESARIO T. PALAYAN Romulo M. Edaño, Jr.

Requisitioning Officer Provincial Administrator
Chairman BAC
Lucena City
NEGOTIATED PROCUREMENT
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 53 (h) of REPUBLIC ACT NO. 9184
(Furnishing and delivery) Date:

QUOTATION (Hauling of materials) Time: (a.m./p.m.)
FOR (Furnishing others) Opened:
(Public Service, etc.)

1 unit ALENAIRE PACKAGED TYPE S#HO200914059
General cleaning using chemicals & check-up of motor
Replacement of bearing, machinery works & repair of shafting
Recharging of Freon gas & repair of valve
Replacement of capacitor 50 MFD
Complete rewinding of fan motor
1 unit ALENAIRE PACKAGED TYPE
1 unit CARRIER WINDOW TYPE
3 units WINDOW TYPE
1 unit NATIONAL 1.5 HP
1 unit CARRIER 2 HP
Replacement of capacitor 7.5 MFD
AMOUNT OF BOND (if required - - - - - - - - - - - - - - - - - - - - - - - - - - P
General Services Office.
(1) that the quotation of the amount

Purchase Order.
EXALTACION Q. ANGELES ARISTEO R. FLORES

Requisitioning Officer Provincial Administrator
Chairman BAC
Lucena City
NEGOTIATED PROCUREMENT
PROCUREMENT THRU NEGOTIATED CONTRACT UNDER SECTION 53 (h) of REPUBLIC ACT NO. 9184
Date:
QUOTATION Time: (a.m./p.m.)
FOR Opened:

150 FOODS
MENU:
Cheeseburger
Softdrinks in Can (Assorted)
xxxxxxxxxxxxxxxxx
AMOUNT OF BOND (if required - - - - - - - - - - - - - - - - - - - - - - - - - - P

General Services Office.
(1) that the quotation of POLARIS INDUSTRIAL TRADING CORP. the amount
Purchase Order.
MERCEDES O. PORNELA ARISTEO R. FLORES

Executive Assistant III Provincial Administrator
Acting APGDH-PGSO Chairman BAC
Province of Quezon
Lucena City
No.
DISBURSEMENT VOUCHER
Mode of
Check Cash Others
Payment
TIN/Employee No. Obligation Request No.

Payee JAVIMED Pharmaceutical Distributor
189-850-810
Responsibility Center
Brgy. Bukal Pagbilao Quezon Office/Unit/Project Code
Address
IPHO - QMC
EXPLANATION AMOUNT
Payment for the purchase of Medicines for use of IPHO -

QMC as per supporting papers hereto attached in the total
amount of . . P 618,426.50
TOTAL P 618,426.50
A. B. Certified
Allotment obligated for the purpose as indicated above Funds Available
Supporting documents complete
Signature Signature
Printed Date Printed Date

Name EVANGELINA M. ONG Name FELIX L. HABITO
Position
Provincial Accountant Position
Provincial Treasurer
Head, Accounting Unit/Authorized Representative Treasurer/Authorized Representative
C. D. Received Payment
Bank Name Date
Signature Check No.
Printed Date Signature

Name RAFAEL P. NANTES Printed Name JAVIMED PHARMECEUTICAL DISTRIBUTOR Date
Position
Provincial Governor OR/Other Documents JEV No. Date
Agency Head/Authorized Representative
No.:
JOURNAL ENTRY VOUCHER
Provincial Government of Quezon Date:
Collection Check Disnursement Cash Disbursement Others
Responsi ACCOUNTING ENTRIES

bility Amount
Center Accounts and Explanation Account Code Ref Debit Credit
Prepared by: Approved by:
EVANGELINA M. ONG
Provincial Accountant

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Annex A

Republic of the Philippines

Payee GODWIN LADLAD, ET AL.

Office PROVINCIAL ENGINEER'S OFFICE

Address Brgy. Talipan, Pagbilao, Quezon

PER DIEM Php 15,000.00

TOTAL Php 15,000.00

Printed Name CESARIO T. PALAYAN Printed Name GODOFREDO E. MATIENZO

SUPPLIER : MAVIL PETRON SERVICE CENTER P.O. NO. :

Obligation of Allotment : Funds Available

EVANGELINA M. ONG FELIX L. HABITO

PROVINCIAL GOVERNMENT OF QUEZON

Department Provincial General Services Office PR No Date:

rms Copy Paper Short 100 275.00 27,500.00

Requested by: Approved by:

PROVINCIAL GOVERNMENT OF QUEZON

Department Janitorial Services - PGSO PR No Date:

Requested by: Approved by:

PROVINCIAL GOVERNMENT OF QUEZON

Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:

Requested by: Approved by:

Agency / Procuring Entity

Department Provincial Engineer's Office PR No Date:

TOTAL P 51, 858.59

Requested by: Approved by:

Designation Provincial Governor Provincial Governor

Provincial Government of Quezon

Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:

Purpose / Remarks: FOR USE AT PEREZ PARK

Requested by: Approved by:

Agency / Procuring Entity

Department PROVINCIAL GENERAL SERVICES OFFICE PR No Date:

Purpose / Remarks: FOR USE OF SFN-303 ASSIGNED TO THE PROVINCIAL GENERAL

Requested by: Approved by:

Item No. Unit Description Quantity

Date Received: Date Inspected:

XXXXXXXX Complete Inspected, verified and found OK As

CESARIO T. PALAYAN EVANGELINA M. ONG

ACCEPTANCE & INSPECTION REPORT

Supplier Gino's Marketing A / R No.

Item No. Unit Description Quantity

Date Received: Date Inspected:

Property/Supply Officer INSPECTED & VERIFIED BY:

Emma B. Serdon, MD., MPH.,FPCHA EVANGELINA M. ONG

Executive Assistant III FELIX L. HABITO

ACCEPTANCE & INSPECTION REPORT

Supplier Gino's Marketing A / R No.

Item No. Unit Description Quantity

Date Received: Date Inspected:

Property/Supply Officer INSPECTED & VERIFIED BY:

MERCEDES O. PORNELA EVANGELINA M. ONG

Request for Quotation

Very truly yours,

ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST

Tel. No./Cellphone No./e-mail address

PROVINCIAL GENERAL SERVICES OFFICE

PRICE QUOTATION / PRO-FORMA INVOICE

ITEM NO. QTY. UNIT ITEM DESCRIPTION UNIT COST

PROVINCIAL GENERAL SERVICES OFFICE

PRICE QUOTATION / PRO-FORMA INVOICE