PRINTER IV: DOT MATRIX, 136 COLUMNS

REQUEST FOR QUOTATION Date: __________ RFQ No.: XII-RF-2026-0205 PR No. 2609300341 Company/Business Name: _______________________________________________________ Address: _____________________________________________________________________ Business/Mayor’s Permit No.: ____________________________________________________ TIN: ________________________________________________________________________ PhilGEPS Registration Number (required): ______________________________ The Philippine Health Insurance Corporation – Regional Office XII, through its Bids and Awards Committee (BAC), intends to procure the project: PRINTER IV: DOT MATRIX, 136 COLUMNS with an Approved Budget for the Contract of SEVEN HUNDRED FORTY THOUSAND SEVEN HUNDRED NINETY TWO PESOS ONLY (PHp740,792.00) through Section 34. SMALL VALUE PROCUREMENT of the Implementing Rules and Regulations of Republic Act No. 12009. Please submit your duly signed quotation addressed to the Bids and Awards Committee (BAC) Chairperson and to the given address below, on or before _________________________ , subject to the compliance with the Terms and Conditions provided on this Request for Quotation (RFQ): LORELIE G. BONILLA, MPA Chairperson, Bids and Awards Committee Philippine Health Insurance Corporation – Regional Office XII CSA Building Cor. Zulueta Street, General Santos Drive Telephone No. (083) 228 – 6239 Email: pro12gsu@philhealth.gov.ph Interested service provider shall also submit a copy of the following documents along with the quotation on or before the above specified deadline of submission of quotation: a. Valid Mayor’s/Business Permit b. PhilGEPS Registration c. Notarized Omnibus Sworn Statement and if applicable, Original Notarized Secretary’s Certificate in case of a corporation, partnership, or cooperative; or Original Special Power of Attorney of all members of the joint venture giving full power and authority to its officer to sign the OSS and do acts to represent the Bidder The Head of the Procuring Entity (HoPE) of the Philippine Health Insurance Corporation – Regional Office XII reserves the right to reject any and all quotations, declare a failure of procurement, or not award the contract in accordance with Section 70 of the IRR of RA No. 12009. For any clarification, you may contact the BAC Secretariat/ General Services Unit at 083-228-6269 or send email to pro12gsu@philhealth.gov.ph. Signed by: Atty. Zainaldin D. Limpao Vice-Chairperson- PRO XII BAC LORELIE G. BONILLA Division Chief IV _ Field Operations Chairperson- PRO XII BAC After having carefully read and accepted the Instructions and Terms and Conditions, I/we submit our quotation/s for the item/s as follows: PRINTER IV: DOT MATRIX, 136 COLUMNS Minimum Technical Specifications Quantity Offered Technical Specification/ Service Statement of Compliance (“Comply” or “Not Comply”) Note: Non-compliance with the minimum required specifications shall be grounds for disqualification 13 UNITS SEE ATTACHED TECHNICAL SPECIFICATIONS ******nothing follows******** FINANCIAL OFFER: Terms of Payment: Payment shall be made through check. Should supplier prefer to receive the payment through direct deposit to their designated bank account, a written authorization letter must be provided. All transaction fees associated with the direct deposit shall be shouldered by the supplier. Payment Details: Banking Institution: _________________________________________________ Account Number: __________________________________________________ Account Name (should be the exact account name as registered in the bank): _________________________________________________ Bank Branch:_________________________________________________ Please quote your best offer for the item/s below. Please do not leave any blank items. Indicate “0” if item being offered is for free. PRINTER IV: DOT MATRIX, 136 COLUMNS Approved Budget for the Contract Total Offered Quotation (Inclusive of VAT) SEVEN HUNDRED FORTY THOUSAND SEVEN HUNDRED NINETY TWO PESOS ONLY (PHp740,792.00) In Figures: In Words: __________________________ ____________________________ Signature over Printed Name Position/Designation ________________________ Office Telephone/Fax/Mobile Nos.