Form 5 (Revised 2017) Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

Ilocos Norte
CERTIFICATE OF REGISTRATION
2019-01-05
Student
: 14-5557 Semester : Second
Number
Name : CEREZO, CHARLES KYLE TUGAOEN Academic Year : 2018-2019
Degree : BS in Civil Engineering Year / Section : 5 - B
Course Code Units Time Day Room/College ASSESSMENT
CE 146 3.00 11-12/2-5 MW/T 208/2011 COE
CE 147 3.00 2-3:30 THF 211 COE Description Amount
CE 148 3.00 1-3/1-2 M/T 212/210B COE
CE 153 3.00 4-5/8-11 MW/M 208/212 COE
CE 192 3.00 8-11 T 214 COE Mutual Aid Fund 25.00
Tuition Fee 1,900.00
CE 193 3.00 8-9/TBA/8-11 W/TBA/F 211/5 COE/ITC
Registration Fee 100.00
CE 199 1.00 3-4/8-10 M/TH 210A/212 COE Library Fee 150.00
Total Units : Medical/Dental Fee 50.00
19.0 Mode of Payment Athletic Fee 65.00
Comp Lab Units : 2.0 Cultural Development Fee 50.00
Non-Comp Lab Units : 2.0 Guidance Fee 40.00
Status: Regular Alay Lakad Fee (Sports 15.00
Full Payment Php 0.00 Enhancement Fee)
SMS Fee 25.00
SCUAA Fee 25.00
1st Installment Php 0.00 Student Body Organization Fee 30.00
University Organ Fee 60.00
Laboratory Fee(Phy/Sci) 300.00
Comp Laboratory Fee 900.00
2nd Installment Php 0.00 TOTAL(Free): Php 3,735.00

Scholarship: Tulong Dunong (CHEd)

3rd Installment Php 0.00

RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 3,735.00
YOU ARE NOW OFFICIALLY ENROLLED

Date & time of enlistment: Fri, Jan 4, 2019 5:47 AM

Date & time approved: Fri, Jan 4, 2019 2:24 PM

NOTE: Submit Form 5 and Free Tuition Waiver (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

DECLARATION OF INTENT UNDER R.A. 10931

(The Universal Access to Quality Tertiary Education Act of 2017)

I CHARLES KYLE TUGAOEN CEREZO , a student of MMSU, hereby declare as follows:

☑ I, with the knowledge of my parents (guardian), hereby avail of the benefits under Republic Act No. 10931, The Universal
Access to Quality Tertiary Education Act of 2017, and therefore will be entitled to government funding for my tuition and
other school fees for my education this Second semester, SY 2018-2019 . As such, I will be covered by the Return
Service requirement of the law.

The Return Service in terms of hours shall be in accordance with approved university policy determined by the formula:

Assessed fee
Return Service Number of hours = Prevailing Regional Wage x8

☐ Further, I freely, voluntarily, on my own volition and accord and without any compulsion form anyone, and with the
knowledge and consent of my parents (or guardian), promised to contribute the amount of this Second semester, AY
2018-2019 . This contribution is made in accordance with said law and shall be accounted for and disbursed in accordance
with the law.

This declaration is for the Academic Year 2018-2019 , Second semester.

FULL NAME OF STUDENT: CHARLES KYLE TUGAOEN CEREZO Student No.: 14-5557
Permanent Address: Turod, LUNA, APAYAO
Degree Program: BS in Civil Engineering Year Level: 5

09397237189
Signature of Student Contact Number

CHARITO JESUS CEREZO LEONILA CEREZO

Printed Name and Signature of Father Printed Name and Signature of Mother
Contact Number: 09357950559 Contact Number: 09184862616

CERTIFICATE AND ACCEPTANCE

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, particularly the benefits thereof and the corresponding obligations
thereunder; and after which he/she declared and affirmed he/she fully and thoroughly understood the same.

This will also serve to formally accept and validate the above declarations of the student in behalf of MMSU.

This 05th day of January 2018, City of Batac, Ilocos Norte.

University Registrar