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Ateneo de Zamboanga Som - Application
Ateneo de Zamboanga Som - Application
Ateneo de Zamboanga Som - Application
School of Medicine
Zamboanga City
Provide three (3) sets of the admission requirements and submit to the SOM Registrar office.
Bring the original copy of the documents.
1
Ateneo de Zamboanga University
School of Medicine
PERSONAL DATA
Name _______________________________________________
Address _____________________________________________ Tel. No: ____________________
2
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
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3
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 __________________
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