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SAINT JOHN'S SCHOOL Unit/Division : SHS

PROCUREMENT REQUEST GOODS AND SERVICES FORM Request No :


Date : 24/8/2017

Cost
No code Name of Product/Services Type/Spec Description/Purpose Qty Price @ Amount

dalam pelajaran dan ekstra kurikuler, banyak


murid yang bermain 2 gitar dalam 1 grup (SMA
1 gitar elektrik Sterling / Squier punya 1 gitar yang harus di servis, dan sudah di 1 4000000 4,000,000
cantumkan di proposal ini)

2 servis gitar SMA (X-Cort) gitar ini dalam kondisi yang kurang baik 1 200000 200,000

ampli untuk gitar elektrik, di gunakan untuk


3 ampli gitar kecil Roland Cube 40 pelajaran band, dan untuk acara di aula, dan 1 3500000 3,500,000
ekstra kurikuler band

kabel ini di gunakan untuk ansambel / band


4 kabel jek untuk laptop dan gadget musik digital (bermain musik dengan 5 120000 600,000
menggunakan aplikasi di laptop dan handphone)

kabel ini di gunakan untuk 2 buah microphone


(@5m) dan tambahan 2 kabel instrument (@3m)
5 kabel canare L-2T2S (meteran) kabel mic stereo 16 30000 480,000
di dalam ruang musik. Kabel microphone lama
kondisinya kadang nyala kadang mati.

jek untuk microphone (merakit sendiri dengan


6 jek xlr neutrik neutrik kabel canare - deskripsi no.5) 4 50000 200,000

amphenol ACPM- jek untuk kabel dari ampli ke speaker (kabel yang
7 jek konektor instrument L RN sudah ada, jeknya patah karena penggunaan) 4 50000 200,000

7 jek konektor instrument amphenol TM2P jek untuk kabel instrument 4 40000 160,000

senar gitar anti karat (bisa di gunakan agak lebih


lama dari senar biasa, dan anti karat, agar senar
tidak cepat karat karena penggunaan banyak
8 senar gitar elixir 0.10-0.46 murid) - Beli dalam jumlah lebih dari 1 4 190000 760,000
dikarenakan untuk cadangan suatu waktu senar
putus dan berkarat, sehingga pelajaran bisa tetap
berjalan lancar

senar bass di dalam ruang musik sudah berkarat,


9 senar bass ernie ball di karenakan penggunaan dalam jangka waktu 1 1 400000 400,000
tahun

digunakan untuk mengikat kabel sehingga


10 velcro kabel ties velcro menjadi lebih rapi 1 50000 50,000

layar lcd keyboard di gedung SMA sudah mulai


11 keyboard Yamaha PSR S 770 Yamaha 1 12500000 12,500,000
rusak bergaris, beberapa menu tidak terlihat

TOTAL Rp 23,050,000
Routine : weekly/monthly/annually Non -Routine

Method of Payment : [ ] Cash [ ] Transfer : 01.30.876.544 (Aloysius Julindra)

Checked by Acknowledged by Approved by


Requested by Treasurer/ Found.
Foundation Chairman Secretary

Julindra Dinah Tanuatmadja Ladislaus Susi Lie Tina Irawaty

UNIT / DIVISION :
Filled by Accounting
Cost code
Total Amount of Budget
Budget used as per (date) ____
Budget request
Remaining Budget
Budget controller /Accounting
Formula: D = A - B - C

Terms :
a. This form can be used on procurement request of products, services, contractual services, etc.
b. Procurement Request Form should be submitted by the Division/Purchasing to the Accounting at the latest of 10 working days before the purchase
c Procurement Report should be submitted at the latest 7 (seven) working days after the date of transaction
equipped with original receipts and supporting documents
NOTE:
Additional row or column can be added/adjusted to this form, if needed
Guideline for filling up the form
SAINT JOHN'S SCHOOL Unit/Division : 1
PROCUREMENT REQUEST GOODS AND SERVICES FORM Request No : 2
Cost code diisi
Budget
Date : 3
controller/Acct
Cost
No Name of Product/Services Type/Specification Description/Purpose Qty Price @ Amount
4 code
1 -
2 -
3 -
4 -
5 -
TOTAL Rp -
5 Routine : weekly/monthly/annually Non -Routine

6 Method of Payment : [ ] Cash [ ] Transfer : __________________________

7 Checked by Acknowledged by Approved by


Request by: Treasurer/ Found.
Foundation Chairman Secretary

sign here sign here sign here sign here sign here
Name & Position Name Name Susi Lie Tina Irawaty

8 UNIT / DIVISION :
Filled by Accounting
Cost code

A Total Amount of Budget


B Budget used as per (date) ____
C Budget request
D Remaining Budget
Budget controller /Accounting
15 Formula: D = A - B - C
Name

Terms :
a. This form can be used on procurement request of products, services, contractual services, etc.
b. Procurement Request Form should be submitted by the Division/Purchasing to the Accounting at the latest of 10 working days before the purchase
c Procurement Report should be submitted at the latest 7 (seven) working days after the date of transaction
equipped with original receipts and supporting documents
NOTE:
Additional row or column can be added/adjusted to this form, if needed
No Note:
1 Fill in by unit/division that request the budget
Those considered as Unit are PG, PR, JHS, SHS
Those considered as Division are Accounting, HRD, IT, PSB, Maintenance, Logistic, Purchasing, Curriculum, Multimedia
2 Write: No/Month/Year
3 Write the date of proposing the Procurement Request Form
4 Write the details and purpose of request of product or services
Write the Budget Code for the Cost Code (if it was not budgeted, write Non Budget )--> fill up by accounting
5 Thick to describe if it is a routine or non-routine transaction
6 Thick to describe the method of payment
If using Bank transfer, please write in the name and the account number (the name/account number should be corresponding to the name of the Company/Store)
7 The approval column should be signed as follow:
Column Requested by : sign and write the name and position of the person who made the Report
Column Checked by : for Units (PG, PR, JHS, SHS) signed by the Principal
for Division (Accounting, HRD, Maintenance, Logistic, Purchasing, etc.) signed by Head of Division (if there is a Head of Division)
Column Acknowledged by : For Accounting, HRD, Maintenance, Logistik, Purchasing, IT, PSB, Multimedia,Kurikulum signed by MGR HRD
For IT, PSB, Multimedia, Kurikulum : signed by Coordinator Curriculum Planning &Development Team
Column Approved by : signed by the Foundation Chairman and the Treasurer
8 Column Budget : fill up by the Budget Controller
NOTE:
Additional row or column can be added/adjusted to this form, if needed
Example 1
SAINT JOHN'S SCHOOL Unit/Division : Maintenance
PROCUREMENT REQUEST GOODS AND SERVICES FORM Request No : 002/April/2016
Date : 5 April 2016

Cost Name of Product/Services Type/Spec Description/Purpose Qty Price @ Amount


No code
1 6-3600 Sewa alat pemotong pohon (borongan) Pemotongan dahan pohon diparkiran 2 Rp 700,000 Rp 1,400,000
SD krn saat ini musim hujan dan dan
pohon sudah tua
2 6-3600 Jasa orang pemotong pohon (borongan) 2 Rp 500,000 Rp 1,000,000
3 6-9100 Kabel Ties 25 cm utk merapikan pipa kabel dilobby 2 Rp100,000 Rp 200,000
4 '6-9100 Kabel Protector 15x15 cm utk merapikan pipa freon 5 Rp20,000 Rp 100,000
5 6-9100 Lampu bohlam 15 watt utk mengganti lampu yang rusak 10 Rp25,000 Rp 250,000
TOTAL Rp 2,950,000
Routine : weekly/monthly/annually Non-Routine

Method of Payment : [ ] Cash [ ] Transfer : __________________________

Checked by Acknowledged by Approved by


Requested by Foundation Treasurer/ Found.
Head of Div MGR HRD Chairman Secretary

signed by signed by signed by signed by signed by


Herman (maintenance) Adi Cohen Susi Lie Tina Irawaty
UNIT / DIVISION : Maintenance
Filled by Accounting
Cost code 6-3600 (Greenery 6-9100 (Building
Cost) Maintenance Cost)
A Total Amount of Budget Rp 24,000,000 Rp 36,000,000
B Budget used as per (date) ____ Rp 5,000,000 Rp 20,000,000
C Budget request Rp 2,400,000 Rp 550,000
D Remaining Budget 16,600,000 15,450,000
Budget controller /Accounting
15 Formula: D = A - B - C
Lusiana
Terms :
a. This form can be used on procurement request of products, services, contractual services, etc.
b. Procurement Request Form should be submitted by the Division/Purchasing to the Accounting at the latest of 10 working days before the purchase
c Procurement Report should be submitted at the latest 7 (seven) working days after the date of transaction
equipped with original receipts and supporting documents
Example 2
SAINT JOHN'S SCHOOL Unit/Division : JHS
PROCUREMENT REQUEST FORM (GOODS AND SERVICES) Request No : 001/April/2016
Date : 3 April 2016

Cost Name of Product/Services Type/Spec Description/Purpose Qty Price @ Amount


No code
1 non budget Printer Merk Canon Karena printer lama utk diruang guru 1 Rp 2,000,000 Rp 2,000,000
2 sdh rusak dan sdh dicek oleh IT : Rp -
3 sudah tidak dapat diperbaiki. Rp -
4 Rp -
5 Rp -
TOTAL Rp 2,000,000
Routine : weekly/monthly/annually Non-Routine

Method of Payment : [ ] Cash [ ] Transfer : __________________________

Checked by Acknowledged by Approved by


Requested by Coordinator CPD Foundation Treasurer/ Found.
Principal
Team Chairman Secretary

signed by signed by signed by signed by signed by


Ani (JHS teacher) Alvina Ladislaus Susi Lie Tina Irawaty

UNIT / DIVISION :
Filled by Accounting
Cost code non budget
A Total Amount of Budget
B Budget used as per (date) ____
C Budget request
D Remaining Budget
Budget controller /Accounting
15 Formula: D = A - B - C
Lusiana

Terms :
a. This form can be used on procurement request of products, services, contractual services, etc.
b. Procurement Request Form should be submitted by the Division/Purchasing to the Accounting at the latest of 10 working days before the purchase
c Procurement Report should be submitted at the latest 7 (seven) working days after the date of transaction
equipped with original receipts and supporting documents