SSCSIP Purchase requisition form by 3yLAz82

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									                                                                    PURCHASE REQUISITION FORM
                                                                 Strenthening Specialised Clinical Services Program
                                                                      Fiji School of Medicine, Private Mail Bag
                                                                             Suva, Fiji: Ph: 679 3311700

                Date                  Requesting Country/Institution                                                                     Phone Contact
     Department a                                                            Address


Item(s) requested
    Quantity               Unit                                                               Description                                                                Unit Price   Total
                                                                                                                                                                                              0
                                                                                                                                                                                              0
                                                                                                                                                                                              0
                                                                                                                                                                                              0
                                                                                                                                                                                              0
                                                                                                                                                                        Grand total           0
Supplier
Number of suppliers considered                                (Attach quotes from the suppliers considered)
Name of preferred supplier and reason(s)

Justification          (Justify who will benefit from the item(s) and briefly describe how the item(s) would support /improve delivery of specialist health services)




Officer making the request                                                                Ministry of health endorsement (Secretary of Health)
Name                                                                                      Name
Designation                                                                               Email
Email                                                                                     Phone Contact
Phone contact                                                                                                                                          Signature

                                                                                      Official Use only:
           Purchase endorsed by clinical advisor(s)?            Yes / No                                                                      Project officer processing the request

                                  Name of Clinical Advisor
                                                Signature

                                                                                                                                                   Date approved

								
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