MS.
U-C0M Form 1 (2015}
Mindanao State Uniuenity
College of Medicine
1• St., Dona Juana Subd., Pala-o, lligan City
,
APPLICATION FORM AY 20_-20_
Print legibly and use separate sheet 1f necessary:
PERSONAL INFORMATION
NAME:
(Family Name) (First Name) Middle Name)
PERMANENT HOME ADDRESS: TEL. NO.:
MAILING ADDRESS (if diff9rent from home addr&ss): TEL. NO.:
,
MOBILE NO.: E-MAIL ADDRESS:
DATE OF BIRTH: PLACE OF BIRTH:
AGE: ISEX:
[] Male [ ) Female
NATIONALITY: IRELIGION:
CIVIL STATUS:
( J Single C1Manied [ ]Widowed [ ] Separated
Are you a member of a CULTURAL MINORITYnNDIGENOUS PEOPLE group?
[ 1No
( ] Yes (pis. specify)
FAIIILY BACKGROUND
FATHER'S NAME: AGE: MOTHER'S NAME: AGE:
OCCUPATION:
--
OCCUPATION:
--
J
OFFICE ADDRESS: OFFICE ADDRESS:
CONTACT NUMBER(S): CONTACT NUMBER(S):
EMAIL ADDRESS: EMAIL ADDRESS:
SPOUSE'S NAME (II married): OCCUPATION: CONTACT NUMBER:
NO. OF BROTHERS: NO. OF SISTERS:
NUMBER OF SIBLINGS • in elementary: _ _ • in elementary: _ _
• in high school: _ _ • in high school: _ _
SIBLING RANK • in college --
--
• incollege
--
• graduated • Q{aduated
--
FINANCIAL BACKGROUND
FATHER'S SOURCE OF INCOME: MOTHER'S SOURCE OF INCOME: SPOUSE'S SOURCE OF INCOME:
[ 1Salary [ J sa1ary [ ] Salary
[ J Business [ ] Business [ ] Business
[ I Convnisaion&/Pen&ion [ ] Commissions/Pension [ ] Commiaaions/Pension
[ ] Others _ _ _ _ _ _ _ __ [ ) Others _ _ _ _ _ __
()Others---------
[ I None [ ] None [ J None
Monthly Income: Monthly Income: Monthly Income:
I
,
SOURCE OF FINANCIAL SUPPORT OF MEDICAL EDUCATION:
[ ] Parents [ J Scholarship (see below)
[ ] Relatlve6 (] Others
DO YOU HAVE A SCHOLARSHIP APPLICATION? STATUS OF APPLICATION:
[] No ( ) Approved
[ ] Yes (specify) ( ) Still being processed
EDUCATIONAL BACKGROUND
For COLLEGE GRADUATES:
School you graduated from: Date of Graduation:
Degree Earned/Latin Honor Postgraduate Studies? [ ] No [] Yes
Postgraduate Degree Earned (MS, PhD)
Have you taken any professional licensure exam? [ J No [ ) Yes (specify, in space bBlow, the exam,ts, data/s taken and gradels)
Are you aJJTently enrolled in any school? [ I No [ ] Yes (answer the questions below)
School: Reason(s): [ ] postgraduate studies
Dates of Attendance: to present [ ] fulfill requirements for application
For GRADUATING STUDENTS:
School you are cunentty enrolled in:
Course: Expected Date of Graduation:
Are you graduating with Honors? [] No [) cum laude [ ] Magna cum laude [ ] Summa cum laude
Are you doing/have you done any research work/thesis? [] No [ ] Yes (answer the questions below)
Research/Thesis Trtle:
Type of Research: [ ] Individual [ ] Group (2 members) [ I Group (3 or more members)
Did you ever have a grade of "INC" in any of your subjects? [ I No [ ]Yes
Did you ever have a grade of"5"fPfFAIL" in any of your subjects? [ I No [ ]Yes
Did you ever DROP any of your subjects? [] No [ ]Yes
SCHOOLS ATTENDED (Include all schools attended. Use back of page if neceSS81}'):
Level Schools Attended Inclusive Years Honor(s)IAward(s) On Graduation
Primary Level (Gr. 1-3)
Intermediate Level (Gr. 4-6)
High School (Gr.7-12)
College
Other
(vocational/trade/diploma)
NATIONAL MEDICAL ADMISSION TEST (NMA T)
QUALIFYING NMAT (rafers to the NMA T you an, submitting for evaluation):
Percentile Rank Date Taken:
IS THIS YOUR FIRST TIME TO TAKE THE NMAT? [ ] Yes [ ] No (answer the questions below)
Number of times you took the NMAT: ( ]2 I J3 [ ] >3
Scores of previous NMAT and date taken: _ __ _ percentile taken _ __ _ __
_ _ _ _ percentile taken _ _ _ _ __
perc.entile taken
MEDICAL SCHOOL APPLICATION
IS THIS THE FIRST TIME YOU ARE APPLYING FOR ADMISSION TO A MEDICAL SCHOOL? [ ] Yes I ] No (see below)
If not, where, when {year) did you apply and what happer1ed to your application{s)?
IS nt1S THE FIRST TIME YOU ARE APPLYING FOR ADMISSION TO MSU COLLEGE OF MEDICINE? [ ] Yea [ ] No ,. . below)
Number of Imes you have applied at MSU-COM? [ ] 2 [ ]3 [ ]>-1
ARE YOU CONCURRENTLY APPLYING FOR ADMISSION TO A MEO. SCHOOL OTHER THAN MSU-COM? [ ] No [ ] Yes {aee belowJ
List schools In the order of prefarenoe: 1.
2.
3.
HAVE YOU EVER ENROLLED IN A MEDICAL SCHOOL? [] No [ ] Yes (see below)
Name of School:
Reason for leaving:
EMPLOYMENT / SERVICE RECORD (If applicable Start from current work)
Position OfficelCompany Inclusive Dates Status of Employment Monthly Salary
'
OTHER DATA:
Child of MS~OM alumnus/ alumna? [ ] No [ ) Yes (n811)8 of a l u m n 1 J ' - - - - - - - - - - - - - - - - - - -
Child of MS~OM Faculty? [ ] No [ ] Yes (name of faculty), _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Child of MSU System Personnel? [ ] No __ .!.[..!]~Y..'::es~(name~~o~f~pe:'!:rsonne~~/)===================---'
Do you have relatives (up 1.o :1" d8gree of consanguinilyJ CURRENTLY EMPLOYED by the MSU System? [ ) No
Name Unit/Department
Do you have relatives (up to :1" degrM of consanguinity) PREVIOUSLY EMPLOYED by the MSU System? [ ] No [ ] Yes (fill up table)
Name Relationship Position Unit/Department
I
Were you ever subjected to cflSCiplinary action by your school's Board of Discipline? [ ] No ( ] Yes (state reason below)
Have you ever been convicted of any civil/ciiminal offense? [ I No [ ] Yes (specify below)
I hereby certify on my word of honor that, I have personally filled out this fonn, and that to the best of
my knowledge, all of the Information contained herein are complete and accurate. I further certify that I have
not withheld any Information from this application that might be an obstacle to my admission. I fully
understand that my admission, and subsequent enrolment, will be automatically cancelled at any time,
should the College find out that I have provided false lnfonnaUe>n or documents to support my application for
admission.
I hereby pledge that, if admitted to the MSU-COM, I will comply with the rules and regulations of the
College now In effect or which hereinafter may be fonnulated.
Signature over Printed Name of Applicant
Date Accomplished
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