QUIRINO STATE UNIVERSITY

ARA - Office of the University Registrar

REGISTRATION FORM

PERSONAL INFORMATION
STUDENT’S LAST NAME: FIRST NAME: MIDDLE NAME: EXTENSION NAME (Jr., Sr., II, etc.)
TOMAS ROGIE LYNE UALAT
Gender: Birthdate: Birth Place: Ethnicity:
[ ] Male JANUARY 23, 2000 ANDRESS BONIFACIO DIFFUN QUIRINO Mother : ILOCANO
[ * ] Female Father: ILOCANO
Ethnicity: Citizenship: Religion: Physical Disability:
Mother : ILOCANO FILIPINO ROMAN CATHOLIC
Father: ILOCANO
CONTAC INFORMATION
Home Address: ANDRES BONIFACIO DIFFUN QUIRINO
Address while Schooling: ANDRES BONIFACIO DIFFUN, QUIRINO
Mobile Number: 09262133956
Email Address: tomasrogie60@gmail.com
Semester: 1st Semester Course &Year: BSED 3YEAR Section: 3A S.Y. : 2020-2021

FOR OLD STUDENT

REGISTRAR’S OFFICE  Present clearance and secure Evaluation of
Grades / Certification of Grades
 Secure Shifting form (if applicable)
 Validating/ Crediting form (if applicable)
 Secure Pre- Registration/ Registration ______________________
Form Signature
Date: ___________
COLLEGE / DEPARTMENT  Present Evaluation of Grades for
evaluation and verification
 Present duly accomplished Shifting form ______________________
and Validating/Crediting form. Signature
 Approval of subjects to be enrolled. Date: ___________

OFFICE OF THE GUIDANCE &  Seek confirmation of scholarship grant.

COUNSELLING, ADMISSIONS AND (Current scholars)
SCHOLARSHIP (OGCAS)  Submit required documents (applicants).

(For scholars and for those who wish to ______________________

apply scholarship ONLY, if not proceed to Signature
next step) Date: ___________

REGISTRAR’S OFFICE  For registration and assessment of fees ______________________

Signature
Date: ___________
CASHIER’S OFFICE  Pay school fees for validation of enrolment ______________________
Signature
Date: ___________

LIBRARY  Present OR of Payment ______________________

 Secure University ID Signature
 Library/E-Library Account Registration Date: ___________

MEDICAL / DENTAL UNIT (CLINIC)  For Physical Examination

_______________________
Signature
Date: ___________

REGISTRAR’S OFFICE  Submit duly accomplished and approved

enrolment form and required documents

_______________________
Signature
 YOU ARE NOW OFFICIALLY
Date: ___________
ENROLLED!

QSU-REG-F002
Rev. 00 (Feb. 11, 2019)
 QUIRINO STATE UNIVERSITY
ARA - Office of the University Registrar

REGISTRATION FORM

PERSONAL INFORMATION
STUDENT’S LAST NAME: FIRST NAME: MIDDLE NAME: EXTENSION NAME (Jr., Sr., II, etc.)
TOMAS ROGIE LYNE UALAT
Gender: Birthdate: Birth Place: Ethnicity:
[ ] Male 01-23-2000 ANDRES BONIFACIO DIFFUN QUIRINO Mother : ILOCANO
[ * ] Female Father: ILOCANO
Ethnicity: Citizenship: Religion: Physical Disability:
Mother : ILOCANO FILIPINO ROMAN CATHOLIC
Father: ILOCANO
CONTAC INFORMATION
Home Address: ANDRES BONIFACIO DIFFUN QUIRINO
Address while Schooling: ANDRES BONIFACIO DIFFUN QUIRINO
Mobile Number: 09262133956
Email Address: tomasrogie602gmail.com
Semester: 1st Semester Course &Year: BSED 3YEAR Section: 3A S.Y. : 2020-2021

FOR OLD STUDENT

REGISTRAR’S OFFICE  Present clearance and secure Evaluation of
Grades / Certification of Grades
 Secure Shifting form (if applicable)
 Validating/ Crediting form (if applicable)
 Secure Pre- Registration/ Registration Form ______________________
Signature
Date: ___________
COLLEGE / DEPARTMENT  Present Evaluation of Grades for evaluation
and verification
 Present duly accomplished Shifting form and ______________________
Validating/Crediting form. Signature
 Approval of subjects to be enrolled. Date: ___________

OFFICE OF THE GUIDANCE &  Seek confirmation of scholarship grant.

COUNSELLING, ADMISSIONS AND (Current scholars)
SCHOLARSHIP (OGCAS)  Submit required documents (applicants).

(For scholars and for those who wish to ______________________

apply scholarship ONLY, if not proceed to Signature
next step) Date: ___________

REGISTRAR’S OFFICE  For registration and assessment of fees ______________________

Signature
Date: ___________
CASHIER’S OFFICE  Pay school fees for validation of enrolment ______________________
Signature
Date: ___________

LIBRARY  Present OR of Payment ______________________

 Secure University ID Signature
 Library/E-Library Account Registration Date: ___________

MEDICAL / DENTAL UNIT (CLINIC)  For Physical Examination

_______________________
Signature
Date: ___________

REGISTRAR’S OFFICE  Submit duly accomplished and approved

enrolment form and required documents

_______________________
Signature
 YOU ARE NOW OFFICIALLY
Date: ___________
ENROLLED!

QSU-REG-F002
Rev. 00 (Feb. 11, 2019)
 QUIRINO STATE UNIVERSITY
ARA - Office of the University Registrar

REGISTRATION FORM
PERSONAL INFORMATION
Student’s Last Name: First Name: Middle Name: Exte’n Name (Jr., ID No.
Sr., etc)
TOMAS ROGIE LYNE UALAT 18-10549
Registering as: [ ] New Student [ * ] Old Student [ ] Transfer in [ ] Lateral Transfer
[ ] Cross Enrollee [ ] Foreign Student

Semester : 1ST Semester School Year: 2020-2021

Gender : [ ] Male Civil Status: [*] Single Name of Spouse:
[ * ] Female [ ] Separated [ ] Married (if Married)
Birthdate: Birthplace: Nationality: Religion: Dialect Spoken:
ANDRES BONIFACIO DIFFUN QUIRINO
01-23-2000 FILIPINO ROMAN ILOKO
CATHOLIC
Home Address: ANDRES BONIFACIO DIFFUN, QUIRINO
Permanent Mailing Address: ANDRES BONIFACIO DIFFUN, QUIRINO
Cellphone Number: 09262133956 Email: tomasrogie60@gmail.com

Are you living with your parents? [ ] No [ * ] Yes

Father’s Name: ROGER TOMAS Occupation TRICYCLE DRIVER
Father’s Ethnic Affiliation: ILOCANO Monthly Income:
Contact Number 09262133956
Mother’s Name: JOSIE TOMAS Occupation HOUSE WIFE
Mother’s Ethnic Affiliation: ILOCANO Monthly Income
Contact Number 09161673310
Are you boarding? [ ] No [ ] Yes Name of
Landlord/Landlady
Boarding House Address:
ABDRES BONIFACIO
Person Supporting you ROGER TOMAS Occupation: DRIVER Address: DIFFUN QUIRINO
(if other than parents) Contact Number: 09556326074
ACADEMIC INFORMATION
Semester: 1st Semester School Year: 2020-2021 Course/ Year/ Section: BSED 3A Major: FILIPINO
SUBJECT ENROLLED
CLASS CODE SUBJECT CODE SUBJECT DESCRIPTION UNITS PROFESSOR SCHEDULE
E211 SMSST 1 Living in the IT Era 3.0 Ms. G Sadang 3:30-5 pm MW JAA310
E212 EDUC 14H Participating Learner-Center 3.0 Dr. R. Guillermo 7:30-8 am MW SED 3
Teaching
E213 EDUC 15B Foundation of Special and Inclusive 3.0 Ms. Alunday 9-10 am MWTh 2:30-3:30 pm
Education BED1
E214 EDUC 18B Assessment in Learning 1 3.0 Ms. DM Santos 1-2:30 pm MW BED 3
E215 EDUC 21C Research 1 3.0 Ms. Nolasco 10-11:30 am MW SED5
E216 FIL 110 Intro sa Pamamahayag 3.0 Agbayani Jeferlyn 10-11:30 am TTh SED4
E217 FIL 111A Pagtuturo at Pagtataya sa Pakikinig 3.0 Ms. C. Baquiran 7:30-9 am TTh SED 4
at..
E218 FIL 118 Panitikang Filipino 3.0 Dr. A.Pattalitan 7:30-10:30 am F SED 4
E219 FIL 113 Pagsulat 3.0 MsM. Jaramillo 1-2:30 pm TTh SED 5
TOTAL 27

DR. AGATON PATTALITAN

Program Chair/Dean

EDUCATIONAL BACKGROUND
Educational Level Name of School Address Year Graduated Honor Received
DIFFUN CENTRAL SCHOOL AURORA WEST,
Intermediate 2012
D,Q
DIFFUN HIGH SCHOOL ANDRES
Secondary 2017
BONIFACIO, D,Q
QUIRINO STATE ANDRES
Collegiate UNIVERSITY
PRESENT
BONIFACIO D, Q

QSU-REG-F002
Rev. 00 (Feb. 11, 2019)