ATENEO DE ZAMBOANGA UNIVERSITY

School of Medicine
Zamboanga City

CHECKLIST FOR APPLICATION REQUIREMENTS

1. Application Fee paid

O.R. No.

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*2. Accomplished Application Form

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3. Transcript of Record (3 copies-photocopy)

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4. Certificate of Graduation (photocopy)

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5. NMAT Report (Original & 2 photocopies)

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6. Certificate of Good Moral Character

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7. Four copies of 2 x 2 Pictures (white background)

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8. Birth Certificate (Photocopy)

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Note: *#2 then photocopy it another 2 copies

ATENEO DE ZAMBOANGA UNIVERSITY

School of Medicine
Application for Admission
(All information will be held confidential)

PERSONAL DATA
Name _________________________________________________________ Nickname ______________
Last Name

First Name

Middle Name

Date of Birth ________ Place of Birth ___________________ Email Address ______________________

Sex _____ Civil Status ________ Religion ___________ Citizenship _________ Ethnicity____________
If married: Name of Spouse __________________________________________ No. of Children ______
Address in Zamboanga City:

Home Address:

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Tel. No: ________ Mobile No: ___________

Tel. No: ________ Mobile No: _____________

Fathers Name ____________________________________ Living? _____________

Age ___________

Educational Attainment ____________________________ Occupation ___________________________

Mothers Name ___________________________________ Living? ______________ Age ___________
Educational Attainment ____________________________ Occupation ___________________________
Combine monthly income of parents __________________
Number of Siblings _________________ Age of Eldest _________________ Age of Youngest _________
Name

Educational Attainment

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Language/Dialects Spoken at Home ________________________________________________________

In Case of Emergency, Person to be notified:
Name _______________________________________________
Address _____________________________________________ Tel. No: ____________________

EDUCATIONAL BACKGROUND
School
Elementary

Year Attended

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High School ___________________________________________

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College

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Degree______________________ Major ______________

Degree ______________________ Major ______________
List other College Courses taken but not completed:
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Honors/Awards received in college _______________________________________________________
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Extra and co-curriculum activities in college
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Have you ever held a job? Describe what you did
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If you are presently employed, what will you do about your job?
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Do you have any experience of Community/Church Service or Involvement?
In what organization (s)? Give also the position (s) you held/continue to hold in each
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OTHER INFORMATION
In a short paragraph, describe yourself and your social life.
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Describe briefly any hobbies, sports and special skill that you engage in and how involved you are with
them.
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Please check where appropriate:
Do you smoke?

( ) Yes

( ) No

Do you drink?

( ) Yes

( ) No

Have you ever been accused of substance abuse?

( ) Yes

( ) No

Have you ever been seriously ill in the past?

( ) Yes

( ) No

Have you ever been in an accident?

( ) Yes

( ) No

( ) Yes

( ) No

Do you or any member of your family have

history of mental illness?

From whom did you learn about Ateneo de Zamboanga University School of Medicine?
( ) Newspaper

( ) Friend/Classmate

( ) Family Member

( ) Former Teacher

( ) Others __________________

What motivates you to pursue a medical career?

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Are there members of your family or relatives who are in the medical profession?
( ) Yes

Who? _______________________________________________________________

( ) No
Did they influence your own career choice?

( ) Yes

( ) No

Who will support you through your medical education?

( ) Parents

( ) Relatives

( ) Scholarship

( ) Grant

Describe briefly any experience/training related to medicine you have had. Example: Red Cross
Volunteer Work, CPR, etc.
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Give a brief statement of whether you would or you would not enjoy staying in a rural community as a
student-doctor of the Ateneo de Zamboanga University School of Medicine
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Describe briefly your idea of a good doctor
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Do you expect to pursue further specialization in a certain field of medicine? Why?
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Applicants Signature