Form 5 (Revised 2017)
Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
Ilocos Norte
CERTIFICATE OF REGISTRATION
2023-03-15
Student
Number
Name
Degree
: 22-031134
Semester
: CORTEZ, MATT ONGAT
: BS in Accountancy
Academic Year : 2022-2023
Year / Section : 1 - A
ASSESSMENT
Course Code
Math 01
SocSc 01
Comm 01
Acc 100
Acc 101
Law 192
PE 02
NSTP 02
Units
3.00
3.00
3.00
3.00
3.00
3.00
2.00
3.00
Total Units
Comp Lab Units
Non-Comp Lab Units
Status: Regular
Time
8-9
9-10:30
1-2:30
10-11
11-12
5:30-6:30/8-10
3-5
8-11
:
23.0
: 0.0
: 0.0
Day
MWF
TTH
TTH
MWF
MWF
M/SAT
T
SAT
Room/College
216 CAS
216 CAS
216 CAS
109 ACC
109 ACC
109 AFF
CLRC CAS
217 ACC
Mode of Payment
Full Payment
PhP 0.00
Description
: Second
Amount
Tuition Fee
2,000.00
Registration Fee
100.00
Library Fee
150.00
Medical/Dental Fee
50.00
Athletic Fee
65.00
Cultural Development Fee
50.00
Guidance Fee
40.00
Sports Enhancement Fee
15.00
SCUAA Fee
25.00
Student Body Organization Fee
30.00
University Organ Fee
60.00
Mutual Aid Fund
25.00
NSTP Fee
150.00
TOTAL(Free): PhP 2,760.00
Scholarship: College Scholar
1st Installment
PhP 0.00
2nd Installment
PhP 0.00
3rd Installment
PhP 0.00
RA 10931, Universal Access to Quality Tertiary Education Act of 2017 Php 2,760.00
YOU ARE NOW OFFICIALLY ENROLLED
Date & time of enlistment: Fri, Jan 13, 2023 9:24 AM
Date & time approved: Fri, Jan 13, 2023 9:33 AM
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
APPLICATION TO AVAIL TERTIARY EDUCATION SUBSIDY
(RA 10931, Universal Access to Quality Tertiary Education Act of 2017)
I MATT ONGAT CORTEZ ,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.
For the Academic Year 2022-2023 , Second semester.
FULL NAME OF STUDENT:
MATT ONGAT CORTEZ
PERMAMENT ADDRESS:
PUROK MABUHAY, Poblacion East, FLORA, APAYAO
DEGREE PROGRAM:
BS in Accountancy
STUDENT NO.:
22-031134
YEAR LEVEL:
1
__________________________
Signature of Student
PETRONILO CORTEZ
BERNADETTE CORTEZ
Printed Name and Signature of Father
Printed Name and Signature of Mother
☐
1. Certificate of residency with name of student applicant, address & date of issuance. Duly signed by the Barangay
Captain with dry seal.
☐ 2. Certificate of Non-Filing of Income Tax Return/BIR Form 2316/ITR if applicable.
☐ 3. PWD ID /Certification from the National Council for Disabilities Affairs (NCDA) specifying the disability(s) for TES 3a
applicants only.
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.
This ___ day of _____________________ 2023, City of Batac, Ilocos Norte.
____________________________________
Registrar
NOTE: If a guardian signs instead of a parent/s, please provide additional information:
1. Why the parent/s could not sign?
_______________________________________________________________
2. What is the (blood) relationship between the student and guardian?
_______________________________________________________________
Republic of the Philippines
Mariano Marcos State University
City of Batac, Ilocos Norte
FREE HIGHER EDUCATION APPLICATION FORM
Second Semester, AY 2022-2023
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:
MATT ONGAT CORTEZ
Contact No.:
09155295916 E-mail address:
Home Address:
PUROK MABUHAY, Poblacion East, FLORA, APAYAO
Religious Affiliation:
Sex:
mattcortez37@gmail.com Civil Status:
☑ Male ☐ Female
☑ Single ☐ Married
Citizenship: FILIPINO
Tribal Affiliation:
II. FAMILY INFORMATION
Name of Father:
PETRONILO CORTEZ
Name of Mother:
BERNADETTE CORTEZ
Who is Supporting your studies?
Parents
Self-Supporting
Spouse (if married)
Others, please specify: ___________________________
If supported by parents, number of siblings below 18 years old:_______
If married and supported by the spouse, number of children below 18 years old: _______
Monthly Family Income
Occupation
Father
If supported by the parents
Mother
Total Monthly Family Income
If supported by spouse
If self-supporting
☐
☐
☐
☐
Does your family belong to any of the following?
4Ps beneficiaries
Listahanan
Not applicable
☐
☐
☐
Estimated Monthly Income
III. STUDENT INFORMATION
Are you a recipient of any scholarship?
Yes
No
Course: BS in Accountancy
Year Level: 1
Type of student:
New
Continuing
Old Returning Student
If new, when was the last school year attended: ____
And in which institution (name and address of school):
____________________________________________
☐
☐
If yes, write the name of the scholarship program and total amount of
stipend per semester.
____________________________________
Do you have any pending scholarship application?
Yes
No
☐
☐
☐
☐
☐
If yes, write the name of the scholarship program:
_________________________________________
I hereby certify as to the correctness of the information provided.
________________________________
Signature of Applicant
Documentary Requirement/s:
Any of the following:
Income Tax Return (ITR) of family members responsible for the financing the student’s
education.
BIR Form 2316
BIR Certificate of Exemption from Filling of ITR
Brgy. Certificate of Indigency or Low Income
Certificate from the DSWD
Overseas Filipino Worker (OFW) Certificate
Employment Contract for OFW’s
Other government-issued documents that indicated income
REMINDER!
To be accomplished and submitted with the
documentary requirement/s to the
Registration Adviser.
(Do not write on this part, for SSD Personnel)
CONFIRMATION SLIP
Date:___________________
This confirms that MATT ONGAT CORTEZ is granted FREE Tuition Fee for the Second Semester of AY 2022-2023.
Assessed by:
Approved by:
________________________________________________
________________________________________________
Printed Name and Signature of Scholarship Coordinator
Printed Name and Signature of SSD Head