PRE-REGISTRATION FORM

(Write in BLOCK LETTERS)

____2ND ___SEMESTER, ACADEMIC YEAR _2021 – 2022__

STUDENT ID NO. 2021-301814

NAME ___________ BRIZ _____ ROCKY JAKE__________ BUBAN __

(Last Name) (First Name) (Middle Name)

STUDENT TYPE New Old If old student, Year 1st 2nd 3rd last

DEGREE SOUGHT BACHELOR OF SCIENCE IN MECHANICAL ENGINEERING

GENDER MALE_________________________
BIRTHDATE JUNE 15, 2002_________ __ ____
CIVIL STATUS SINGLE__________________________
RELIGION ROMAN CATHOLIC_______________
NATIONALITY FILIPINO_________________________
ADDRESS BRGY. CULAJAO ROXAS CITY, CAPIZ
PHONE NUMBER 09569226535__________
PRESENT POSITION _________________________________
Position _________________________________
Agency _________________________________
Address _________________________________
In case of emergency:
Parent/Guardian RAYMUND BRIZ ____
Address BRGY. CULAJAO ROXAS CITY, CAPIZ
Contact Number 09913705647______________________
Email Address _________________________________
COURSES ENROLLED: COURSE CODE COURSE TITLE UNITS
MATH 122 INTEGRAL CALCULUS 3
PHYS 121 PHYSICS FOR ENGINEERS 4
COMP 121 COMPUTER FUNDAMENTALS 1
AND PROGRAMMING
GE 103 ARTS APPRECIATION/ 3
PAGPAPAHALAGA SA SINING
GE 104 MATHEMATICS IN THE MODERN WORLD/ 3
MATEMATIKA SA MAKABAGONG DAIGDIG
GEE 103 LIVING IN THE IT ERA 3
PE 102 FITNESS EXERCISES 2
NSTP 102 ROTC/CWTS/LTS 3
22
________________________
Signature of Student
Registration Adviser ENGR. EDMIL JHON B. ARIQUES
Date Assessed _____________________________
Scholarship _____________________________
 Document Type: Document Code INS-F01
FORM
ISO 9001:2015 Revision No. 00

Document Title: Effective Date June 25, 2018

PRE-REGISTRATION FORM Page 1 of 1

__2ND Semester AY: 2021 - 2022

Name: ROCKY JAKE BRIZ Sex:_MALE_______Age__19_______

Course and Year: BACHELOR OF SCIENCE IN MECHANICAL ENGINEERING
Address: BRGY. CULAJAO ROXAS CITY, CAPIZ
Parent/Guardian: RAYMUND BRIZ

Course Course Title Unit Faculty

Number Credit
MATH 122 INTEGRAL CALCULUS 3
PHYS 121 PHYSICS FOR ENGINEERS 4
COMPUTER FUNDAMENTALS AND
COMP 121 PROGRAMMING 1
ARTS APPRECIATION/ PAGPAPAHALAGA SA
GE 103 SINING 3
MATHEMATICS IN THE MODERN WORLD/
GE 104 MATEMATIKA SA MAKABAGONG DAIGDIG 3
GEE 103 LIVING IN THE IT ERA 3
PE 102 FITNESS EXERCISES 2
NSTP 102 ROTC/CWTS/LTS 3
22

__________________________
Name and Signature of Student

This is to certify that the student indicated above is qualified to enroll this
__ 2nd__Semester/Summer, Academic Year_ 2020 - 2021 __.

Noted: Received:

_ ENGR. ANACLETO M. CORTEZ, JR._ ________________________

Program Coordinator Registrar