Professional Documents
Culture Documents
Form 5 19 050232
Form 5 19 050232
Form 5 19 050232
Scholarship: -- NONE --
3rd Installment Php 0.00
RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 2,940.00
YOU ARE NOW OFFICIALLY ENROLLED
NOTE: Submit Form 5 and TERTIARY EDUCATION SUBSIDY Form (signed by Parents only) to your Department on the first day of classess.
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
I ACIER PAMBID MANUEL ,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.
__________________________
Signature of Student
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.
____________________________________
Registrar
NOTE: If a guardian signs instead of a parent/s, please provide additional information:
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: ACIER PAMBID MANUEL Sex: ☑ Male ☐ Female
Contact No.: 09054117863 E-mail address: ACIERPAMBID25@GMAIL.COM Civil Status: ☑ Single ☐ Married
Home Address: CENTRO EAST, Nagpatayan, BANNA (ESPIRITU), ILOCOS NORTE
Religious Affiliation: Tribal Affiliation: Citizenship: FILIPINO
________________________________
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
CONFIRMATION SLIP
Date:___________________
This confirms that ACIER PAMBID MANUEL is granted FREE Tuition Fee for the First Semester of AY 2021-2022.
________________________________________________ ________________________________________________
Printed Name and Signature of Scholarship Coordinator Printed Name and Signature of SSD Head