Form 5 (Revised 2017) Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

Ilocos Norte
CERTIFICATE OF REGISTRATION
2018-08-10
Student
: 13-5320 Semester : First
Number
Name : ROSETE, ARVIN JAY I. IGLESIA Academic Year : 2018-2019
Degree : BS in Computer Engineering Year / Section : 5 - A
Course Code Units Time Day Room/College ASSESSMENT
CPE 151 4.00 11-12/2-5 MWF/M 115 COE Description Amount
CPE 190 2.00 10-12 T 116A COE
ELECT 2 3.00 8-9 MWF 115 COE Tuition Fee 900.00
Registration Fee 100.00
Library Fee 150.00
Medical/Dental Fee 50.00
Total Units :
Athletic Fee 65.00
9.0 Mode of Payment Cultural Development Fee 50.00
Comp Lab Units :
Guidance Fee 40.00
1.0
Alay Lakad Fee 15.00
Non-Comp Lab Units :
Full Payment Php 2,015.00 SMS Fee 25.00
0.0
SCUAA Fee 25.00
Status: Regular
Student Body Organization Fee 30.00
Mutual Aid Fund 25.00
1st Installment Php 1,115.00 University Organ Fee 60.00
Group Insurance Fee 30.00
Comp Laboratory Fee 450.00
2nd Installment Php 585.00 TOTAL: Php 2,015.00

3rd Installment Php 315.00 Scholarship: --NONE--

For Students with Fees to be paid

Option 1: Online Payment
1. Pay your fees online thru https://epaymentportal.landbank.com
2. Use the following details:
Merchant's Name: Mariano Marcos State University
Type of Fee: Tuition Fee
Mode: Full Payment
Option 2: Offline Payment
1. Print 3 copies of this form.
2. Pay your fees at the Cashier's Office - FEM Hall (Admin. Bldg) - Batac, CTE-Laoag, or CIT-Laoag.

Date & time of enlistment: Fri, Aug 10, 2018 12:50 AM

Date & time approved: Fri, Aug 10, 2018 3:04 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 ARVIN JAY I. IGLESIA ROSETE , a student of MMSU, hereby declare as follows:

☑ I, with the knowledge and consent of my parents (or guardian), freely and voluntarily, and not under any form of duress
waived and renounced my option to avail of the benefits under Republic Act No. 10931, the Universal Access to Quality
Tertiary Education of 2017, and therefore will not be entitled to government funding for my tuition and other school fees for
my college education this First semester, SY 2018-2019 . As a consequence of such waiver, I will not be covered by the
Return Service requirement of the law. The reason/s for the waiver/renunciation is/are:
_______________________________________________________________________.

☐ 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: ARVIN JAY I. IGLESIA ROSETE Student No.: 13-5320
Permanent Address: 6, Dadalaquiten Norte, SINAIT, ILOCOS SUR
Degree Program: BS in Computer Engineering Year Level: 5

09261253765
Signature of Student Contact Number

ARNULFO ROSETE VALENTINA ROSETE

Printed Name and Signature of Father Printed Name and Signature of Mother
Contact Number: 09299705386 Contact Number: 09288351891

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 10th day of August 2018, City of Batac, Ilocos Norte.

University Registrar