Form 1

Revised March, 2014

1





University of the East Appl. No.
RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC. OR No.
64 Barangay Doa Imelda, Aurora Blvd., Quezon City 1113, Philippines Date :


APPLICATION FOR ADMISSION
For Academic Year: 20 - 20
[ ]First Trimester/Semester [ ]Second Trimester/Semester
[ ]Third Trimester [ ] Summer

ATTACH 2X2
Colored Photo with
white background




College of Medicine


PERSONAL INFORMATION

Name:
(Last Name) (First Name) (Middle Name)
Permanent Home Address:


Current Address:

Cell phone No.: _ Landline No.: Email Address:

Date of Birth: _ Place of Birth:

Age: Sex: [ ] Male / [ ] Female Citizenship: Religion:

Civil Status: [ ] Single [ ] Married [ ] Divorced [ ] Legally Separated

Name of Spouse (if married): Occupation:

Parents: (Mark with + if deceased)

Father:
Occupation:
Office Address:
Mother:
Occupation:
Office Address:



Contact No/s.:

Email Address:
Contact No/s:

Email Address:

Are you a permanent resident of another country? [ ] Yes [ ] No If yes, what country?
Permanent Home Address:
Provincial Address (if any):
Form 1
Revised March, 2014
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Guardian (other than Parents): Occupation:

Address:

Contact no/s.: Email Address:

Do you have relatives who graduated from UERMMMCI? [ ]Yes [ ]No

Name: College:
Present Address:
Contact No/s: Relationship to the Applicant:

Character References: Give names and addresses of three persons (not relatives) who have known you and
with whom the Committee on Admission can correspond to. Must include someone who has known you as
student in high school /or college and who has taught/supervised you in class.

a.
b.
c.


EDUCATIONAL INFORMATION

Are you a college graduate of any foreign school? [ ] Yes [ ] No
What was the last school attended?
Degree earned:


Schools Attended:
Primary: _ Inclusive years:
Address:

Intermediate: _ Inclusive years:
Address:

High School: Inclusive years:
Inclusive years:
Address:


College:
Address:
_ Inclusive years:
Inclusive years:
Form 1
Revised March, 2014
3




Honors/Awards Received: (pls. list details)
a.
b.
c.

Extra- curricular activities in High School / or College: (pls. list details)
a.
b.
c.
Have you applied for admission to other school/s? [ ] Yes / [ ] No
Name of School: _ Status of Application:

Are you a child of UERM Alumni? [ ] No
[ ] Yes, my mother is a UERM Alumna [ ] Yes, my father is a UERM Alumnus
Class College Class College


Graduating with Honors? [ ] Yes [ ] No Please check applicable box, if graduating with Honors:
[ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention
[ ] Others - pls. specify:





Have you taken the NMAT? [ ] Yes [ ] No Date taken:


Score obtained:

Have you applied for admission with other medical school/s? [ ] Yes / [ ] No

Name of School: Status of Application:

Have you studied in any Medical School/s? [ ] Yes/ [ ] No
If yes, where and when
Revised March, 2014
4
Form 1


FINANCIAL INFORMATION:

How do you plan to finance your education? Please indicate in percentage (%):

Your own resources: _ Parents: Other relatives:
Other sources (scholarships, PVA, special funds, etc.):
Combined annual income of Parents:


I hereby certify that:
a. I have not withheld any information from this application that might be an obstacle to my admission;
b. I have personally filled out this form and that to the best of my knowledge, all the information contained
herein are complete and accurate.
c. I have not been debarred from other schools.


I fully understand that:
To be considered for admission to the UERMMMCI College of Medicine, I must be a holder of a
Bachelors Degree in Arts or Sciences, which must have been earned not later than the end of the
second semester immediately preceding the school year for which I am seeking admission;


I hereby pledge that:
a. My enrolment will be automatically cancelled if the School has found out that I have provided false
information or documents to support my application for admission;
b. If admitted to the UERMMMCI, I will comply with all the rules and regulations of the Center now in
effect or which hereinafter may be formulated;
c. I will join only in campus organizations recognized by the schools.
NOTE:
ALL DOCUMENTS SUBMITTED IN SUPPORT OF YOUR APPLICATION BECOME THE PROPERTY OF THE
UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC. HENCE, WILL NOT BE
RETURNED ANYMORE TO YOU.





Signature over Printed Name of Applicant


Date Accomplished:

Revised March, 2014
5
Form 1

NOT TO BE FILLED UP BY THE APPLICANT.


GENERAL AVERAGE (RECENT O.T.R.):


REQUIREMENTS:
[ ] Transcript of Records (Original)
[ ] Application Fee/ Psychological Exam Fee
[ ] Transfer Credentials
[ ] Diploma (certified true copy)
[ ] Recommendation Letter
[ ] Passport size, colored pictures (3 pcs.)
[ ] Application Letter
[ ] PRC License and Certificate 0f Board Rating
[ ] Certificate of Professional Training/ certificate of Employment
[ ] Birth Certificate
[ ] Marriage Certificate (if applicable)





[ ] Accepted [ ] Deferred [ ] Denied





/
Dean / College Secretary / Date




To be filled up by the Registrar Office Staff:

For College of Medicine: For Colleges of : For the Graduate School:
BS/BA: Nursing
Allied Rehabilitation Sciences
Medical Technology
College General Average
__________________
G.W.A: H.S./ College General Ave.
Fs:
NMAT %ile: