Document Code COM-FRM-001

MARIANO MARCOS STATE UNIVERSITY

College of Medicine
Revision No. 0 Page 1 of 2
ADMISSION/APPLICATION FORM
Effectivity Date August 2019

APPLICATION FOR ADMISSION Photo

2x2
AY ______________

NAME:
(Please Print) LAST FIRST MIDDLE

DATE OF BIRTH (mm/dd/yyyy) RESIDENTIAL ADDRESS

PLACE OF BIRTH

SEX AGE TELEPHONE NO.

CIVIL STATUS PERMANENT

ADDRESS

CITIZENSHIP

E-MAIL ADDRESS TELEPHONE NO.

FATHER’S NAME ADDRESS

OCCUPATION TELEPHONE NO.

MOTHER’S NAME ADDRESS

OCCUPATION TELEPHONE NO.

GUARDIAN’S NAME ADDRESS

EDUCATIONAL BACKGROUND
INCLUSIVE SCHOLARSHIP
YEAR
NAME OF SCHOOL DEGREE DATES OF S/ ACADEMIC
LEVEL GRADUATE
(Write in Full) COURSE ATTENDANCE HONORS
D From To
RECEIVED
ELEMENTARY
SECONDARY
COLLEGE
GRADUATE
STUDIES

Give an honest evaluation of yourself, especially your strengths and weaknesses. (Use additional sheet if necessary)

How important is medical education to you? (Use additional sheet if necessary)

Disclaimer: Reproduction of this form is allowed subject

to compliance to the Documented Information Procedure
established by MMSU.
 Document Code COM-FRM-001
MARIANO MARCOS STATE UNIVERSITY
College of Medicine
Revision No. 0 Page 2 of 2
ADMISSION/APPLICATION FORM
Effectivity Date August 2019

Who would finance your medical education?

Give a brief statement of whether you would or you would not enjoy staying to serve in the rural community as a
doctor. (Use additional sheet if necessary)

Why did you choose MMSU College of Medicine?

Have you applied in other medical school(s)? [ ] YES [ ] NO If yes,

What school? status of
application?

Have you ever been enrolled in other medical school(s)? [ ] YES [ ] NO If yes,
What school? Date/school
year

IF FOREIGN APPLICANT: ACR VISA

NO.: STATUS:

IMPORTANT: The application for admission does not mean outright acceptance to the College of
Medicine.

I certify to the veracity of the above information, any evidence of fraud in the credentials/documents
submitted will automatically nullify my enrollment in the College of Medicine.

I certify further that if accepted, I will abide by the rules and regulations of the College and CHED.

OR
No.
Signature of Applicant
Date:

Disclaimer: Reproduction of this form is allowed subject

to compliance to the Documented Information Procedure
established by MMSU.