Cebu Institute of Medicine For ADMISSIONS Committee Only:

School: NMAT:
79 F. Ramos St., Cebu City, Philippines, 6000 Course: GWA:
Tel Nos. (6332) 253-3124; 253-7412 TOR: LOR: INT
Fax Nos. (6332) 253-9127; 255-5756 O.R. No.:
Email: [email protected] Date
Fee:
APPLICATION FORM FOR ADMISSION
Instructions: All items must be filled out completely.
Write legibly in BLACK ink or print using block ink.

NAME: PASSPORT
(Surname) (Given) (Middle)
PICTURE WITH
Home Address:
NAME
Tel. No.
Mailing Address:
(Within 3 months from
Tel. No.
application)
Working E-mail address: Cell No.

PERSONAL DATA:
Age: Sex: M F Ht. (m): Wt. (kg): BMI: Citizenship (at birth)
Date of Birth: Place of Birth: Religion: Citizenship (now)
If married: Name of spouse: Occupation: No. of children:

MEDICAL HISTORY: Please list on the spaces provided any illness (physical/mental) or any physical
disability which you have incurred in the last 5 years.

Allergies: Medications (maintenance):

Contact person in case of emergency: Contact number:

SOCIAL HISTORY: Do you have any current pending cases in court? YES NO

EDUCATIONAL BACKGROUND:
Level School Attended Location Years Attended
Primary
Junior High
Senior High
College
Any awards earned during high school graduation: YES NO , if yes, please specify below:
Academic Awards:
Special Awards:
After finishing high school, were you enrolled every semester until you earned your baccalaureate degree/s?
YES NO If NO, please state why:

Baccalaureate/s Degree Obtained: Date of Graduation:

Masters/Post-Graduate Degree Obtained, if any: Date of Graduation:
Did you earn academic honors in college? YES NO if YES, please list:

For those who had gap years prior to taking up medicine, what did you do during this time? Please specify
inclusive years.

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Other than academic subjects and routine activities, what other activities are you most interested in, in a more
than usual degree?
School organizations Music: Vocal/Instrument Others:
Religious activities Theater Arts
Socio-civic action Dance/Ballet
Sports Creative writing
Please also list down other skills or work experiences that you have which may be useful in the study or practice
of medicine.

Is this your first time to seek admission to the Cebu Institute of Medicine? YES NO
If NO, when was the last time you applied?

Is this your first time to seek admission to the medical course? YES NO
If NO, please check below whichever applies to you:
Accepted and enrolled at (Name of medical school)
Accepted but didn’t enroll at (Name of medical school)
Application was not approved

FAMILY BACKGROUND:
Father’s Name: Mother’s Name:
Occupation: Occupation:
Address: Address:

Contact No.: Contact No.:

Check which of the following applies regarding parents marital state:
Living together Separated Divorced Others (specify):

What is/are their source(s) of income?

Salaries Business, please specify:
Commissions Others not mentioned:
Pension
Who will sponsor your medical education?
Self
Parents Others:
Phil. Veterans benefit
Scholarship:
Approved:
Still processing:
Planning to apply: Yes

Siblings’ Names Highest Educational Attainment Degree/Course

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Do you have any siblings enrolled in CIM? YES NO
If YES, please state his/her name and year level:

Do you have any relatives who are alumni in this institution? YES NO
If YES, please state his/her name and their relationship to you

What was the greatest influence in your decision to take up medicine as a career?
Childhood dream Illness in family Others:
Advice of parents Prestige of profession
Inspired by family doctors Awareness of health needs
Advice of relatives/friends of community
If you will push through studying here in Cebu City, where will you most likely stay?
With parents Others:
With relatives
Apartment/condo
Boarding house/dormitory

Please list down the medical schools you have applied (or will apply) to for the coming school year, in order of
your preference, INCLUDING the CEBU INSTITUTE OF MEDICINE:
1st preference Others:
2nd preference
3rd preference

NOTE TO APPLICANT: All communications pertaining to this application will be sent to you at your mailing
address. If you will not be at this address for some time, arrange for someone to transmit the communication to
you, or notify us for any change of address as soon as possible.

Send this application to: The Admissions Committee

Cebu Institute of Medicine
F. Ramos Street
6000 Cebu City, Philippines

Submit this application together with the following: a. One (1) copy of the transcript of college records
reflecting also High School records (for evaluation) which should include all courses taken with final grades,
except for those of the 2 nd semester of the current school year, b. letter of reference from two (2) former college
teachers who can vouch for your moral character and please indicate their addresses, & c. remittance for filing.

I hereby certify on my word of honor that the

foregoing entries are true and correct to my knowledge. For ADMISSIONS
Committee Only:
Do not fill up.

Signature over printed name Accepted:

Date signed: Regrets:

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The members of the admissions committee would like to know you better.
Instructions: Please write CONCISELY about the following topics in essay form, and ONLY on the spaces
provided for. WRITE LEGIBLY in black ink. DO NOT TYPE.

A. Describe your family dynamics.

B. Describe a situation in which you had a considerable responsibility. Give your reflection on this
and your learnings from this situation.

C. Describe your strengths and weaknesses (both academic and personal in relation to your aspirations to
becoming a physician.
PERSONAL:

ACADEMIC:

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FORM 1 || Page | 4