Form 5 (Revised 2017) Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

Ilocos Norte
CERTIFICATE OF REGISTRATION
2019-08-10
Student
: 19-050728 Semester : First
Number
Name : DASALLA, RACHELLE N/A Academic Year : 2019-2020
Degree : BS in Ceramic Engineering Year / Section : 1 - A
Course Code Units Time Day Room/College ASSESSMENT
MATH 34 3.00 11-12/10-12 M/W 217/205 COE
Math 01 3.00 2-3 MWF RM 10 CAB
CHE 10 4.00 1-2/8-11 MWF/F RM 2/213 CAB/CAS Description Amount
CERE 1.00 8-9 W 223 COE
100
GS 100 3.00 2-3:30 TTH 223 CAB Tuition Fee 2,200.00
SocSc 01 3.00 10:30-12 TTH RM 10 CAB Registration Fee 100.00
PE 01 2.00 8-10 T C. COURT Library Fee 150.00
CWTS 1 3.00 8-11 SAT CAMPUS COE Medical/Dental Fee 50.00
ENGG 10 3.00 1-2/8-9/9-11 TTH/M/M 224/217/224 COE Athletic Fee 65.00
Cultural Development Fee 50.00
Total Units : Guidance Fee 40.00
25.0 Mode of Payment Alay Lakad Fee (Sports 15.00
Comp Lab Units : 0.0 Enhancement Fee)
Non-Comp Lab Units : 2.0 SCUAA Fee 25.00
Status: Regular Student Body Organization Fee 30.00
Full Payment Php 0.00 Mutual Aid Fund 25.00
University Organ Fee 60.00
Group Insurance Fee 30.00
Entrance Fee 50.00
1st Installment Php 0.00 School ID Fee 100.00
NSTP Fee 150.00
Laboratory Fee(Phy/Sci) 200.00
TOTAL(Free): Php 3,340.00
2nd Installment Php 0.00
Scholarship: --NONE--

3rd Installment Php 0.00

RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 3,340.00
YOU ARE NOW OFFICIALLY ENROLLED

Date & time of enlistment: Thu, Aug 1, 2019 12:04 AM

Date & time approved: Thu, Aug 1, 2019 11:17 AM

NOTE: Submit Form 5 and TERTIARY EDUCATION SUBSIDY Form (signed by Parents only) to your Department on the first day of classess.

DATA PRIVACY CONSENT

I explicitly and unambiguously consent to the collection, processing and storage of my personal data by MMSU for the purpose(s)
described in the MMSU Data Privacy Notice (http://www.mmsu.edu.ph/about/mmsu-dataprivacy-notice).

Signature of Student
 Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
City of Batac, Ilocos Norte

APPLICATION TO AVAIL TERTIARY EDUCATION SUBSIDY

(RA 10931, Universal Access to Quality Tertiary Education Act of 2017)

I RACHELLE N/A DASALLA ,a student of MMSU, freely and voluntarily, and not under any form of duress, and with the knowledge
and consent of my parents (or guardian), as indicated by their respective signatures below, hereby apply for TERTIARY EDUCATION
SUBSIDY, as provided under RA 10931, the Universal Access to Quality Tertiary Education of 2017, as follows:

☐ TES 2: Educational expenses, which I am qualified to by reason of my status as a financially challenged student.
☐ TES 3a: Additional allowance for special services, personal assistance, transportation, equipment and supplies, which I am
qualified to by reason of my standing as a PWD student.
☐ TES 3b: Additional one-time benefit to cover cost of obtaining professional license or certificate for the first-time, such as
notarial fees, review classes fees, insurance premium and documentary fees.

The student and parents declare, promise and guaranty that all required supporting documents will be submitted, and any and all
amounts issued and received by reason hereof, shall be solely and exclusively spent, disbursed or used for the purpose for which it
was granted.

For the Academic Year 2019-2020 , First semester.

FULL NAME OF STUDENT: RACHELLE N/A DASALLA STUDENT NO.: 19-050728

PERMAMENT ADDRESS: LIW-LIWA, Crispina, BANNA (ESPIRITU), ILOCOS NORTE
DEGREE PROGRAM: BS in Ceramic Engineering YEAR LEVEL: 1

__________________________
Signature of Student

ROLLY AGDINAOAY LEONORA AGDINAOAY

Printed Name and Signature of Father Printed Name and Signature of Mother
☐ 1. Certificate of residency with name of student applicant, address & date of issuance. Duly signed by the Barangay Captain
with dry seal.
☐ 2. Certificate of Non-Filing of Income Tax Return/BIR Form 2316/ITR if applicable.
☐ 3. PWD ID /Certification from the National Council for Disabilities Affairs (NCDA) specifying the disability(s) for TES 3a
applicants only.

CERTIFICATION

This will serve to certify that the provisions of Republic Act No 10931, the Universal Access to Quality Tertiary Education of 2017,
were explained to above-named student, and that the student in turn explained this document, the benefits he/she applied to, and the
corresponding duties obligations thereunder, to his/her parents, and the latter gave consent to this application.

This ___ day of _____________________ 2019, City of Batac, Ilocos Norte.

____________________________________
Registrar
NOTE: If a guardian signs instead of a parent/s, please provide additional information:

1. Why the parent/s could not sign?

_______________________________________________________________
2. What is the (blood) relationship between the student and guardian?
_______________________________________________________________
 Republic of the Philippines
Mariano Marcos State University
City of Batac, Ilocos Norte

FREE HIGHER EDUCATION APPLICATION FORM

First Semester, AY 2019-2020

Directions: Fill -up by putting a check mark ( ? ) on the appropriate box or by writing the needed information. Please write legibly.

I. PERSONAL INFORMATION
Name: RACHELLE N/A DASALLA Sex: ☐ Male ☑ Female
Contact No.: 09386573713 E-mail address: MARKEEAGDINAOAY@GMAIL.COM Civil Status: ☑ Single ☐ Married
Home Address: LIW-LIWA, Crispina, BANNA (ESPIRITU), ILOCOS NORTE
Religious Affiliation: Tribal Affiliation: Citizenship: FILIPINO

II. FAMILY INFORMATION

Name of Father: ROLLY AGDINAOAY
Name of Mother: LEONORA AGDINAOAY
Who is Supporting your studies?
☐ Parents
Does your family belong to any of the following?
☐ 4Ps beneficiaries
☐ Self-Supporting
☐ Listahanan
☐ Spouse (if married)
☐ Not applicable
☐ Others, please specify: ___________________________
If supported by parents, number of siblings below 18 years old:_______
If married and supported by the spouse, number of children below 18 years old: _______
Monthly Family Income
Occupation Estimated Monthly Income
Father
If supported by the parents
Mother
Total Monthly Family Income
If supported by spouse
If self-supporting

III. STUDENT INFORMATION

Are you a recipient of any scholarship?
Course: BS in Ceramic Engineering
Year Level: 1 ☐ Yes ☐ No
Type of student: If yes, write the name of the scholarship program and total amount of stipend
☐ New per semester.
☐ Continuing ____________________________________
☐ Old Returning Student Do you have any pending scholarship application?
If new, when was the last school year attended: ____
And in which institution (name and address of school):
☐ Yes ☐ No
If yes, write the name of the scholarship program:
____________________________________________
_________________________________________

I hereby certify as to the correctness of the information provided.

________________________________
Signature of Applicant
Documentary Requirement/s:
Any of the following:
Income Tax Return (ITR) of family members responsible for the financing the student’s
REMINDER! education.
BIR Form 2316
To be accomplished and submitted with the
BIR Certificate of Exemption from Filling of ITR
documentary requirement/s to the Brgy. Certificate of Indigency or Low Income
Registration Adviser. Certificate from the DSWD
Overseas Filipino Worker (OFW) Certificate
Employment Contract for OFW’s
Other government-issued documents that indicated income

(Do not write on this part, for SSD Personnel)

CONFIRMATION SLIP

Date:___________________

This confirms that RACHELLE N/A DASALLA is granted FREE Tuition Fee for the First Semester of AY 2019-2020.

Assessed by: Approved by:

________________________________________________ ________________________________________________
Printed Name and Signature of Scholarship Coordinator Printed Name and Signature of SSD Head