Bicol University

OFFICE OF ADMISSIONS
Legazpi City

APPLICATION FORM
BICOL UNIVERSITY COLLEGE OF MEDICINE
SY _______________

To Students and Parents:

THIS FORM IS ONLY FOR APPLICANTS FOR THE COLLEGE OF MEDICINE.
CAREFULLY READ THE GENERAL INFORMATION FOR BUCM applicants and the Attach a recent
contents of this form before filling in the information asked. 2” x 2”
Only CORRECTLY and COMPLETELY FILLED OUT FORMS will be accepted. Photograph here.

----------------------------------------------------------------------------------------------------------------------- Please sign photograph

(Do not fill below this line) at the back

Application No. _____________________________

Recorded by:_______________________________ GWA : _________________

Amount Paid: ______________________________ INTERVIEW :_________________

OR No.__________________Date:_____________ NMAT : _________________

Date Filed: ________________________________

I – Personal Information: (Please type or print in ink)

Name: ____________________________________________________________________________________
(Family) (First) (Middle)
MM / DD / YEAR
Age: __________ Sex: M F Civil Status: Single Date of Birth:

Married Others, Specify: _________________

Citizenship: Filipino Place of Birth: ______________________________

Natural-born

Naturalized (attach supporting papers)

________________________ (others, please specify) Religion: ________________

Home Address: _____________________________________________________________________________

Country: ______________________ Postal Zipcode: ______________ Telephone No. ___________________

Email Address: _______________________________

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II – Educational Background: (List of all the schools you have attended or are attending)

Certificates/degrees
Inclusive dates earned or course
School / Location of attendance currently enrolled in Date recieved
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Is this the first time you are applying for admission to a medical school? YES NO

If not, where, when, (year/s) did you apply, and what happened to your application(s)?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Are you concurrently applying for admission to a medical school other than the B.U. College of Medicine?
If yes, at what medical school(s)?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

III – Family Background:

A. Aggregate Average Monthly Income of Parents of Applicant:

Less than Php 20,000 Php 31,000 to Php 50,000

Php 21,000 to Php 30,000 Greater than Php 50,000

B. Who will spend for your education? ____________________________

C. Parent’s Data Father Mother (Maiden Name)

Name: _____________________________ _________________________________

Educational
Attainment: _____________________________ _________________________________

Occupation: _____________________________ _________________________________

Age: __________ ___________

Address: _____________________________ _________________________________

Tel. No./CP No. ____________________________ _________________________________

D. Number of siblings: _____________

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 IV – Personal Views:

A. Why do you want to be a medical doctor?

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

B. What is “healthy lifestyle” for you?

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

C. What special talents / skills will you contribute to the College of Medicine?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

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APPLICANT’S CERTIFICATION

I HEREBY CERTIFY ON MY HONOR THAT ALL THE INFORMATION HEREIN CONTAINED

IS TRUE AND CORRECT AND THAT I AM NOT CURRENTLY ENROLLED IN ANY MEDICAL
SCHOOL, OTHERWISE MY APPLICATION FOR ENTRANCE IN BICOL UNIVERSITY WILL BE
RENDERED INVALID.
FURTHER, IF ACCEPTED TO THE MEDICAL DEGREE PROGRAM, I AGREE TO A
MANDATORY RETURN-SERVICE AS A PARTIALLY SUBSIDIZED SCHOLAR OF THE
GOVERNMENT.

___________________________________ ___________________________________________
Signature of Applicant Signature of Parent/Guardian over Printed Name

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