Professional Documents
Culture Documents
Som Application
Som Application
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 _______________________________________________
2
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
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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