Author: Beth

COLLEGE OF MEDICINE
University of the Philippines Manila
APPLICATION FOR ADMISSION
(Regionalization Program)
Academic Year _______________________________
Learning Unit I Learning Unit III
Name ______________________________________
School last attended: _________________________
____________________________________________
Course: _____________________________________
Region: _____________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
( Do not fill below this line)
Application No. ___RP-2021__________________ GWAG : __________________________
Issued : _____________________________________ INTERVIEW : __________________________
Amount Paid : ________________________________ NMAT : __________________________
OR No. ________________ Date: _________________
Date Filed: ____________________________________

(Please type or print in ink)
Name: _______________________________________________________________________________________________
(Family) (First) (Middle)
Age: __________ Sex: ___________ Civil Status: _______________ Date of Birth: ________________________________
(Month) (Date) (Year)
Citizenship: Filipino Place of Birth: ______________________________________
___________________________ (others, please specify)
Natural-born
Naturalized (attach supporting papers)
Present mailing address: _________________________________________________________________________________
Telephone (Mobile/Landline): _____________________________Email Address:___________________________
Place where you have resided longest : _____________________________________________________________________
Parents: (Indicate if deceased)
Father: _____________________________________ Occupation: ___________________________________
Address: ____________________________________ Tel. (Mobile/Landline): __________________________
Mother : ____________________________________ Occupation: ___________________________________
Address: ____________________________________ Tel.(Mobile/Landline): ___________________________
Guardian: (Person supporting you if other than your parents)
Name: ______________________________________ Occupation: ____________________________________
Address: _____________________________________ Tel.(Mobile/Landline): ____________________________
Person responsible for you in the city if you are not residing with either your parents or guardian.
Name: _______________________________________ Occupation: ____________________________________
Address: ______________________________________ Tel.(Mobile/Landline): ___________________________
Educational background: (List in chronological order all the schools you have attended or are attending)
Certificates/degrees
Inclusive dates earned or course
School / Location of attendance currently enrolled in Date received
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Is this the first time you are applying for admission to a medical school? ___________________________________________
If not, where, when, (year/s) did you apply, and what happened to your application (s)?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Are you concurrently applying for admission to medical school other than the U.P. College of Medicine?
If so, at what medical school (s)?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
For applicants to the Regionalization Program (RP) and Indigenous People (IP) Categories:
The applicant who applies to the RP and IP categories is REQUIRED to sign a contract with his/her parent(s) as co-signatories. (RP Brochure and Acceptance to Serve & Assumption of Liability (ASAL) Agreement furnished)
Are you applying to the RP Category: Yes No
Are you applying to the IP Category: Yes No
ALL OTHER APPLICANTS for admission to the UP College of Medicine are REQUIRED to sign a RETURN
SERVICE AGREEMENT (RSA) with his/her parent(s)/guardians as co-signatories.
(Handbook on Return Service furnished)
Please list 3 references who can easily be contacted by the Admissions Committee. References should include two from the last school you attended and one from the community.
Name Address and Telephone Number
______________________________________________ ___________________________________________
___________________________________________
______________________________________________ ___________________________________________
___________________________________________
______________________________________________ ___________________________________________
________________________________________
Signature
_______________________________________
Date

Attach a recent
2” X 2”
photograph here.
Please sign photograph
In front.

CHECKLIST FOR REQUIRED DOCUMENTATION AND INFORMATION NEEDED TO APPLY TO LEARNING UNIT III,UP COLLEGE OF MEDICINE FOR ACADEMIC YEAR _______________________________________ :
A complete application which includes:
1. _________ Properly accomplished Application Form
2. _________ Original copy of Transcript of Records for at least 3 1/2 years of Baccalaureate program.
3. _________ Four copies (2X2) pictures
4. _________ PSA/NSO Birth Certificate (a certified true copy /photocopy is acceptable provided the original is shown for verification).
5. _________ For naturalized Filipino Citizens, original Certificate of Naturalization and
one (1) photocopy of the same issued by the Commission on Immigration and Deportation.
6. _________ Latest Income Tax Return of parent (s).
7. _________ DOST Clearance (for DOST scholars).
8. _________ FOR ALL REGIONALIZATION PROGRAM (RP) & INDIGENOUS PEOPLE (IP)
APPLICANTS: ACCEPTANCE TO SERVE AND ASSUMPTION OF LIABILITY (ASAL) AGREEMENT & REPLY SLIP (Refer to Primer on the Regionalization Program)
9. _________ FOR ALL OTHER APPLICANTS: RETURN SERVICE AGREEMENT (RSA) & REPLY
SLIP (Pls. see Handbook on Return Service Obligation Policy)
Any lacking item (s) enumerated above will invalidate application.
Member of a Cultural Minority/Indigenous People group?
_________ Yes ( If yes, submit a Certification of Membership obtained from)
•Office of Northern Cultural Minorities/Indigenous People
•Office of Southern Cultural Minorities/Indigenous People
•Office of Muslim Affairs
__________ No
Child of U.P. Personnel?
__________ Yes (If yes, submit Certification of Employment obtained from U.P. HRDO).
__________ UPCM Faculty
__________ No
IV. Child of U.P. College of Medicine alumnus / alumna?
__________ Yes (If yes, name of Alumni _______________________________ Class___________________)
__________ No
Permanent home address: _______________________________________________________________________
_____________________________________________________________________________________________
Region I Region II Region III Region IV Region V Region VI
Region VII Region VIII Region IX Region X Region XI Region XII
CAR CARAGA ARMM NCR
VI. Ever enrolled in a medical school?
___________ Yes ( If yes, need not apply)
___________ No
VII. NMAT taken?
___________ Yes ( If yes, submit a photocopy of the result)
___________ No ( If no, take the NMAT given in ___________________ or earlier)
Application form1/rev4AY2014-2015