Form 5 (Revised 2017) Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

Ilocos Norte
CERTIFICATE OF REGISTRATION
2018-10-24
Student
: 18-070192 Semester : First
Number
Name : ADINA, JOHN ANIKIEN TOMBOC Academic Year : 2018-2019
Degree : BS in Industrial Technology (Garments Technology) Year / Section : 1 - A
Course Code Units Time Day Room/College ASSESSMENT
SocSc 01 3.00 3-4 MWF CIT
SocSc 02 3.00 10-11 MWF 208 CIT
Description Amount
Math 01 3.00 7:30-9 TTH 103 CIT
Fil 01 3.00 10:30-12 TTH 103 CIT
GT 111 3.00 1-2/8-11/2-5 T/WF/TTH GT 1 CIT Tuition Fee 2,000.00
NSTP 01 3.00 4-5:30 TTH CIT Registration Fee 100.00
PE 01 2.00 8-10 M DTI-1 CIT Library Fee 150.00
GT 112 3.00 1-2/2-5/7-10 T/TTH/WF GT 2 CIT Medical/Dental Fee 50.00
Athletic Fee 65.00
Total Units : Cultural Development Fee 50.00
23.0 Mode of Payment Guidance Fee 40.00
Comp Lab Units : 0.0 Alay Lakad Fee 15.00
Non-Comp Lab Units : 4.0 SMS Fee 25.00
Status: Regular SCUAA Fee 25.00
Full Payment Php 0.00 Student Body Organization Fee 30.00
Mutual Aid Fund 25.00
University Organ Fee 60.00
Group Insurance Fee 30.00
1st Installment Php 0.00 Entrance Fee 50.00
Laboratory Fee(Phy/Sci) 600.00
School ID Fee 100.00
NSTP Fee 150.00
2nd Installment Php 0.00 TOTAL(Free): Php 3,565.00

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

RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 3,565.00
YOU ARE NOW OFFICIALLY ENROLLED

Date & time of enlistment: Fri, Aug 3, 2018 1:32 AM

Date & time approved: Mon, Aug 13, 2018 12:49 AM

NOTE: Submit Form 5 and Free Tuition Waiver (signed by Parents only) to your Department on the first day of classess.
 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 JOHN ANIKIEN TOMBOC ADINA , 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 First 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 First 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 , First semester.

FULL NAME OF STUDENT: JOHN ANIKIEN TOMBOC ADINA Student No.: 18-070192
Permanent Address: RIGONAN, Brgy. 4 Nalupta (Suabit)(Pob.), CITY OF BATAC, ILOCOS NORTE
Degree Program: BS in Industrial Technology (Garments Technology) Year Level: 1

09666716391
Signature of Student Contact Number

ALLAN ADINA MYLA TOMBOC

Printed Name and Signature of Father Printed Name and Signature of Mother
Contact Number: 09454827450 Contact Number: 09973458340

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 24th day of October 2018, City of Batac, Ilocos Norte.

University Registrar