Republic of the Philippines

City of Manila Republic of the Philippines

OSPITAL NG MAYNILA MEDICAL CENTER City of Manila
OSPITAL NG MAYNILA MEDICAL CENTER

DRIVERS TRIP TICKET

DRIVERS TRIP TICKET

DATE: _______________
AUTHORIZED DRIVER: __________________ PLATE NO: ___________ DATE: _______________
AUTHORIZED DRIVER: __________________ PLATE NO: ___________

NAME OF TIME
PASSENGER DESTINATION PURPOSE OUT IN NAME OF TIME
PASSENGER DESTINATION PURPOSE OUT IN

The purpose of the vehicle above descried person/persons named for the
purpose indicated is/are hereby authorized. The purpose of the vehicle above descried person/persons named for the
purpose indicated is/are hereby authorized.

Accompanying person/s: ______________________________________________

Accompanying person/s: ______________________________________________

____________________________________________
Medical Officer on Duty/Representative Party ____________________________________________
Medical Officer on Duty/Representative Party

Approved by: __________________________________

(DO, AMD, AO, COC) Approved by: __________________________________
(DO, AMD, AO, COC)

Speedometer reading, if any:

At the beginning of the trip ____________ kms Speedometer reading, if any:
At the end of the trip ____________kms At the beginning of the trip ____________ kms
Balance in total: _______ liters At the end of the trip ____________kms
Balance in total: _______ liters
I hereby certify to the above correction soft statement record of travel.
I hereby certify to the above correction soft statement record of travel.

____________________ ______________________________
Signature of Driver Signature of Guard on Duty ____________________ ______________________________
Signature of Driver Signature of Guard on Duty