XAVIER UNIVERSITY (Ateneo de Cagayan) 9000 Cagayan de Oro City
Philippines
APPLICATION FOR ADMISSION TO XU- DR JOSE P RIZAL SCHOOL OF MEDICINE
INSTRUCTIONS FOR COMPLETING THE APPLICATION FORM FOR ADMISSION:
1. Items in the Application Form must be filled out completely. Please print legibly.
2. Answer all questions as well as you can.
3. The applicant should attach a recent 2" x 2" photograph on the application form.
4. An applicant MUST submit a photocopy of his/her transcript of records for evaluation. A student who expects to graduate at the end of the summer session should also submit a certification from his college registrar or other competent school authority that he will graduate in summer. It is preferred that the subject/s to be taken in summer be listed.
5. Then submit complete requirements:
__ duly filled up admission application form __ photocopy of transcript of records
__ for graduates, photocopy of certification of weighted average grade
__ photocopy of official NMAT result (cut off 60%tile, taken not more than two (2) years from the time of application)
__ medical examination result from school designated physicians to the School of Medicine administration office on or before 15 June 2018.
IMPORTANT NOTES:
1. Incomplete requirements will not be accepted.
2. A personal interview is an essential part in the selection process. Applicants should set an appointment for interview with the School of Medicine Admission Committee.
DR JOSE P RIZAL SCHOOL OF MEDICINE Xavier University, Ateneo de Cagayan 9000 Cagayan de Oro City, Philippines
Date______________________
Application for Admission For the Academic Year 20 ___ 20 ___
(Note: All applicable items must be filled out completely in black ink)
1. Name of Applicant _____________________________________________________
(Family Name) (First Name) (Middle Name)
HEREBY applies for Admission to the Dr Jose P Rizal School of Medicine of Xavier University, and submits hereunder facts as true and correct statements of his/her history and education.
Home Address: _____________________________________________________
_____________________________________________________
Email address _________________ Contact Number_________________
Mailing Address: ____________________________________________________
____________________________________________________
2. PERSONAL DATA
Age: ________ Sex: ________ Citizenship: __________ Religion:____________
Civil Status: __________ Height (cm.) ______ Weight (kg.) _____________
Date of Birth : ______________ Place of Birth:________________________
If married, name of Spouse: _______________________________________
Address of Spouse: _______________________________________________
Occupation of Spouse: ____________________________________________
Have you been convicted of any court offense? ______ Yes _____ No ____
IF YES, please explain using additional sheet/s if necessary.
________________________________________________________________
Medical History: Please list any illness/physical defects which should be taken into consideration in planning your program of studies and school activities
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Date of your last physical examination: ________________________________
2 x 2 photo
Have you ever been forced to stop schooling for a month or more because of poor health?
_______YES_______NO: IF YES, give details and dates
__________________________________________________________________
__________________________________________________________________
3. FAMILY BACKGROUND
Father's Name: ____________________ Occupation: _____________________
Mailing Address: __________________________ Contact No._________________
Mother's Name: ____________________ Occupation:_____________________
Mailing Address: ___________________________Contact No. ________________
What is/are their source/s of income? (check appropriate item) State annual income __ Salaries ________ __ Rentals _________ __ Others____________
__ Commission ______ __ Farms _________
__ Pension ________ __ Business _________
How many siblings do you have? Brothers ________ Sisters ___________
Name of siblings Age Educational Attainment Civil Present occupation Course/Year Graduated Status
___________________ ____ __________________ _____ __________________
___________________ ____ __________________ _____ __________________
___________________ ____ __________________ _____ __________________
___________________ ____ __________________ _____ __________________
___________________ ____ __________________ _____ __________________
___________________ ____ __________________ _____ __________________
4. EDUCATIONAL BACKGROUND
School Year
Course School/s Attended From To Title/Degree Elementary:__________________ _________ _________ ___________
Secondary: __________________ _________ _________ ___________
College :
1st Year ____________________ _________ _________ ___________
2nd Year ____________________ _________ _________ ___________
3rd Year ____________________ _________ _________ ___________
4th Year ____________________ _________ _________ ___________
5th Year ____________________ _________ _________ ___________
Other collegiate course taken (degree if any)____________________________________
Where and when taken _____________________________________________________
________________________________________________________________________
For those who did not proceed to Medicine immediately after graduation from college: What did you do after graduation?
______ Took another course Where and When?__________________
______ Worked as employee Where and When?__________________
______ Worked in family/own business Where and When?__________________
______ Others: ________________________________________________
________________________________________________
________________________________________________
Have you applied for admission to any other medical school/s this year or in the previous years? _________. IF YES, at what medical school/s, when and what is the status of your application? _____________________________________________________________
5. ABOUT YOUR FUTURE PLANS
How will your medical education be supported? Answer in percentages % _______________ Parents ________________Scholarship
_______________ Your own resources ________________Private Benefactor/s _______________ Relatives Others________________________
If your family does not live in the Cagayan de Oro area, where will you most likely be staying? (state if with relatives, in boarding homes, etc.)
__________________________________________________________________
6. REFERENCES
Give the names and addresses of three persons (not relatives) who have known you and can character references, with whom the Admissions Committee can correspond. At least two of of those persons should have taught you in a science laboratory class.
Name Institution Business Address & Email address/
Contact Number
____________________ _____________________ _______________________________
____________________ _____________________ _______________________________
____________________ _____________________ _______________________________
7. OTHERS
State any additional information concerning yourself which you believe might be of help to the Admissions Committee in evaluating your application. (College Honors, Research, Membership in Societies, Athletics, College Publication, Student Government, School Organizations and any other extra-curricular activities in school.)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
In the space below,
(a) Give a brief and candid description of your personality, your goals and plans for your career. Use additional sheets if necessary:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(b) Clarify any unusual aspects of your records. Use additional sheets if necessary:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
I fully understand that, among other requirements to be satisfied for admission to the Dr Jose P Rizal School of Medicine of Xavier University, I must be a holder of a Bachelor's Degree in Arts or Sciences and must have all the qualifications set forth in CHED Memorandum Order No 18 series of 2016, Policies, Standards and Guidelines for the Doctor of Medicine (M.D.) Program Section 17 on Students.
I HEREBY PLEDGE that if admitted to the Dr Jose P Rizal School of Medicine of Xavier University, I shall comply with the rules of the School in effect or which hereinafter may be formulated through its Bulletin of Information.
My enrolment will be automatically cancelled if I have enrolled under FALSE PRETENSES, such as the use of irregular credentials, withholding certain credentials, being debarred from readmission for college for reason of poor scholastic standing or disciplinary action and my graduation in due time depends, in the completion of the academic and other requirements as required by law and/or directive of the Commission On Higher Education.
Date Accomplished: ______________ ____________________________________
(Signature over printed name of applicant)
:cbs 2017.10.18
