Gate Pass For Materials

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GATE PASS FOR MATERIALS

This is to authorize Mr./Ms. of


to take the following materials out of the hospital:

Description of items Serial No. Qty. Reason

Conformed: Approved by:


Employee name & signature Name & signature

For Security Guard use only:

Checked by: Date of release: Time:


Security Guard on Duty
(name & signature)

For borrowed/repaired items:

Date returned: Condition:

Returned by: Received by:


(name & signature) (name & signature)

(3 copies – 1 SG; 1borrower, 1 for the employee)

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