Form 5 (Revised 2017) Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

Ilocos Norte
CERTIFICATE OF REGISTRATION
2019-03-20
Student
: 18-020086 Semester : Second
Number
Name : FLORES, HASMINE M Academic Year : 2018-2019
Degree : AB in English Language Year / Section : 1 - A
Course Code Units Time Day Room/College ASSESSMENT
ABEL 111 3.00 9-10 MWF MMC CAS
ABEL 112 3.00 10:30-12 TTH NEW SPL CAS Description Amount
Fil 02 3.00 9-10:30 TTH R14 CAs
Comm 01 3.00 8-9 MWF MMC CAS
Math 01 3.00 10-11 MWF 206 CAS Tuition Fee 1,700.00
Registration Fee 100.00
PE 02 2.00 2-4 M GYM
Library Fee 150.00
NSTP 02 3.00 8-11 SAT CAS Medical/Dental Fee 50.00
Total Units : Athletic Fee 65.00
20.0 Mode of Payment Cultural Development Fee 50.00
Comp Lab Units : 0.0 Guidance Fee 40.00
Non-Comp Lab Units : 0.0 Alay Lakad Fee (Sports 15.00
Status: Regular Enhancement Fee)
Full Payment Php 0.00 SMS Fee 25.00
SCUAA Fee 25.00
Student Body Organization Fee 30.00
1st Installment Php 0.00 University Organ Fee 60.00
Mutual Aid Fund 25.00
Group Insurance Fee 30.00
NSTP Fee 150.00
2nd Installment Php 0.00 TOTAL(Free): Php 2,515.00

Scholarship: --NONE--
3rd Installment Php 0.00

RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 2,515.00
YOU ARE NOW OFFICIALLY ENROLLED

Date & time of enlistment: Mon, Jan 7, 2019 3:32 PM

Date & time approved: Thu, Jan 10, 2019 9:48 AM

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 HASMINE M FLORES , 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: HASMINE M FLORES Student No.: 18-020086

Permanent Address: Bgy No. 8 Margaay, VINTAR, ILOCOS NORTE
Degree Program: AB in English Language Year Level: 1

09266553719
Signature of Student Contact Number

ARSENIO FLORES HERMINIA FLORES

Printed Name and Signature of Father Printed Name and Signature of Mother
Contact Number: 0915000372 Contact Number: 09201569477

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 20th day of March 2018, City of Batac, Ilocos Norte.

University Registrar