ATENEO DE ZAMBOANGA UNIVERSITY

School of Medicine
Zamboanga City

CHECKLIST FOR APPLICATION REQUIREMENTS

1. Application Fee paid O.R. No. ______________________

*2. Accomplished Application Form ______________________

3. Transcript of Record (3 copies-photocopy) ______________________

4. Certificate of Graduation (photocopy) ______________________

5. NMAT Report (Original & 2 photocopies) ______________________

6. Certificate of Good Moral Character ______________________

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

8. Birth Certificate (Photocopy) ______________________

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:

_____________________________________ _______________________________________
_____________________________________ _______________________________________
_____________________________________ _______________________________________
Tel. No: ________ Mobile No: ___________ Tel. No: ________ Mobile No: _____________

Father’s Name ____________________________________ Living? _____________ Age ___________

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

Name Educational Attainment

________________________________________ _______________________________________
________________________________________ _______________________________________
________________________________________ _______________________________________
________________________________________ _______________________________________

Language/Dialects Spoken at Home ________________________________________________________

In Case of Emergency, Person to be notified:

Name _______________________________________________
Address _____________________________________________ Tel. No: ____________________
EDUCATIONAL BACKGROUND
School Year Attended
Elementary ___________________________________________ _________________________
High School ___________________________________________ _________________________
College ___________________________________________ _________________________
Degree______________________ Major ______________
Degree ______________________ Major ______________

List other College Courses taken but not completed:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Honors/Awards received in college _______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Extra and co-curriculum activities in college
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you ever held a job? Describe what you did
_______________________________________________________________________________
_______________________________________________________________________________
If you are presently employed, what will you do about your job?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
OTHER INFORMATION
In a short paragraph, describe yourself and your social life.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Describe briefly any hobbies, sports and special skill that you engage in and how involved you are with
them.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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
Do you or any member of your family have
history of mental illness? ( ) Yes ( ) No

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?

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

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
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Describe briefly your idea of a good doctor
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Do you expect to pursue further specialization in a certain field of medicine? Why?

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

_______________________
Applicants Signature