UPM NATIONAL GRADUATE OFFICE FOR THE HEALTH SCIENCES

 Padre Faura corner Ma Orosa Street Ermita 1000 Manila

 Tel nos: (63 2) 526-5870, 523-1495  Telefax: (63 2) 523-1498
 E-mail: upm_ngohs@yahoo.com  Website: www.upm.edu.ph/gradoffice

APPLICATION FORM

Please type or print clearly and tick the box of your choice (if
appropriate).

- Page 1 of 2 -UPM NGOHS Application Form

 UPM NATIONAL GRADUATE OFFICE FOR THE HEALTH SCIENCES
 Padre Faura corner Ma Orosa Street Ermita 1000 Manila
 Tel nos: (63 2) 526-5870, 523-1495  Telefax: (63 2) 523-1498
 E-mail: upm_ngohs@yahoo.com  Website: www.upm.edu.ph/gradoffice

Application OR No 9. Nationality :  H o
Filipino ________________________ nors, if
: ______________
_____ any:____________________
Specify region of
DEGREE PROGRAM : origin:__________ 17. E-_
_________________ mail:______________
F 3. Degree :  BA/BS
______________
oreig  MD 
COLLEGE/UNIT : ner 18. Name, address and M/MA/MS
___________________________ tel no of person to (Specify)___________
Specify citizenship
___ be notified in case ________________
________________ of emergency:
ACADEMIC YEAR & University:
Specify country of __________________ ____________________
SEMESTER OF origin: _________________ _____
APPLICATION: _____________________ Inclusive Years:
_______________ ____________________
___________________________
______________________ 10. Civil Status : B. ACADEMIC Honors, if any:
Single Married QUALIFICATIONS ___________________
A. PERSONAL DATA Separated
Widow/Widower 1. Degree:  BA/BS
 MD 
1. Surname: 11. Permanent M/MA/MS
INCOMPLETE and/or INCORRECT
__________________ Address:
_____ DOCUMENTS
(Specify) WILL NOT BE
___________________ _____________________
ENDORSEDC. FOR EVALUATION
2. First Name: ___________________ ____ PRESENT
__________________ ___________________ EMPLOYMENT
University:
___ _________________ ____________________ Position/Job Title
3. Middle Name 12. Mailing Address _____ :_________________
:_________________ : Inclusive Years: _
___ ___________________ ____________________ Name of
4. Title :  Mr  Ms ___________________ Honors, if any: Institution:__________
 Prof  Dr ___________________ _____________________
_______
_________________
5. Sex:  Female  Job Description:
Male 13. Telephone 2. Degree:  BA/BS
____________________
6. Date of Birth :  MD  M/MA/MS
(Res.):_________________ ____________________
________/________/ (Specify)___________
14. Telephone _________________ ____________________
_________ ____________________
mm dd yy University: ______________
(Office):_______________ ____________________
7. Age: 15. Mobile _____ Address :
__________________ Number:________________ Inclusive ________________________
________ _____ Years:______________ ____
8. Place of birth: 16. Fax : _______ ______________________
________________ ________________

- Page 2 of 2 -UPM NGOHS Application Form

 UPM NATIONAL GRADUATE OFFICE FOR THE HEALTH SCIENCES
 Padre Faura corner Ma Orosa Street Ermita 1000 Manila
 Tel nos: (63 2) 526-5870, 523-1495  Telefax: (63 2) 523-1498
 E-mail: upm_ngohs@yahoo.com  Website: www.upm.edu.ph/gradoffice

Telephone/Fax Nos (for PhD Nursing

: Applicants)
_________________  An original and one
(1) photocopy of official
Inclusive years : receipt of application fee
_________________ F. GENERAL  Four (4) passport-
size pictures
D. FINANCIAL EQUIREMENTS
Additional Requirements
SUPPORT  An original and a for Foreign
photocopy of complete Applicants
Annual Income and signed application Two (2)
form (2 pages) photocopies of TOEFL (or
Self:_________________ An original and twoits equivalent) score of at
(2) photocopies of Officialleast 500 (written test) or
_______________
(Original) Transcript of173 (computerized tests),
TotalRecords (Please seeoriginal to be
Household:_____________ attachment) presented for
________  A Certified Trueverification or a
Copy and one (1)certification from the
photocopy of Diploma withuniversity previously
the university/college sealattended that English is
 Scholarship,
and signature of theused as the medium of
fellowship or study registrar in ink instruction
privilege (specify)  Two (2) copies of Affidavit of
Curriculum Vitae Support/Certification of
 Two(2)complete Financial Capability in
________________________ and signedEnglish
_________________ Recommendations (forms Official Transcript of
provided in the ApplicationRecords and Certified True
 Others: Packet). The sealedCopy of Diploma in
___________________________ envelope must beEnglish. If written in
addressed to: THEanother language,
___________________________ DIRECTOR, NGOHS these documents must
 An Essay on an 8be translated to English
1/2’” x 11” sheet of paperand authenticated by
__________________________________describing your motivation
the Philippine
______________________ for pursuing graduateembassy /consul from
study and your view ofcountry of origin
self-directed learning as a Two (2)
E. ENROLLMENT method of instruction. photocopies of passport,
STATUS Likewise, provide aoriginal to be presented
PREFERENCE description of your Submit all application documents to:
for verification
research interest Ms Kristie Faro or Mr Warren Bautista
Load:  Part-Time(6-10  A photocopy of PRC
License/Certificate (for
units/semester)
MRS, MRS-SP, MS
 Full-Time(12-18 Dentistry and MA in
units/semester) Nursing Applicants)
Deadline for submission 
of application
A dissertation
documents: proposal abstract and
For Second Semester: 30 September published 2003
creative works
For First Semester: 22 April 2004
MS Dentistry: 17 October 2003
MS Clinical Epidemiology:
18 December 2003
- Page 3 of 2 -UPM NGOHS Application Form