Application No.:________________

WEST VISAYAS STATE UNIVERSITYCOLLEGE OF MEDICINE

Iloilo City

APPLICATION FOR ADMISSION

______________________________

(Date)

The Committee on AdmissionsCollege of MedicineWest Visayas State UniversityIloilo City

Gentlemen:

Please consider me an applicant for admission to the WVSU-College of Medicine for school year __________________________.

I have read the regulations of the WVSU-College of Medicine and promise to abide by them.

Here are my personal data and other pertinent documents for appraisal as well as three hundred fifty pesos for application fee.

Very truly yours,

______________________________ (Signature over Printed Name)

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GUARDIAN’S / PARENT’S CERTIFICATION

I have given permission to my child ___________________________________to enroll at the WVSU-College of Medicine this coming school year.

______________________________ (Guardian / Parent)

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DEAN’S / REGISTRAR’S CERTIFICATION

This is to certify that________________________________________________an applicant for admission to the WVSU-College of Medicine, is a member of the (graduating/graduated)class of________________of the _______________________.

He/She is a person of good moral character and integrity.

_____________________________ (Dean / Registrar)

WEST VISAYAS STATE UNIVERSITYCOLLEGE OF MEDICINE

Iloilo City

STUDENT’S PERSONAL DATA

Name:__________________________________________________________________Date of Birth:______________________ Age:________________________________Place of Birth:_____________________ Citizenship: _________________________Home Address:____________________ Sex:________________________________Phone Number:____________________ Civil Status:_________________________City Address:______________________ Religion:____________________________Phone Number:____________________ Sibling Rank:________________________Father:___________________________ Occupation:_________________________Mother:__________________________ Occupation:_________________________Address of Parents:________________ Phone Number of Parents:_____________Guardian:________________________ Address & Phone Number:____________Elementary School:________________ Year Graduated:_____________________Secondary School:_________________ Year Graduated:_____________________College or University Attended:____________________________________________

NMAT:

How many times have you taken the NMAT?_________________________________Specify dates: First:__________________ Percentile Rank:_______________

Second:________________ Percentile Rank:_______________Third:_________________ Percentile Rank:_______________

FOR DEGREE HOLDERS:

Degree Earned:__________________________________________________________Major:_____________________________ Minor:_____________________________Date of Graduation:__________________ S.O. No.:____________________________Academic Honors if any:__________________________________________________Have you attended other medical schools?____________________________________If yes, where?____________________________________________________________Reasons for leaving:______________________________________________________

FOR GRADUATING STUDENTS:

Course Being Taken:_____________________________________________________Major:____________________________ Minor:_____________________________Tentative Date of Graduation:______________________________________________General Weighted Average (seven semester work):____________________________

C E R T I F I C A T I O N

I hereby certify on my honor that the aforementioned data are true and correct. I understand that any dishonesty or misinformation on my part shall be ground for the disqualification of my application to the WVSU-College of Medicine.

_______________________________________ (Signature of Applicant over Printed Name)

Paid Under OR No.:_______________Date Paid:_______________________Amount: ________________________Posted By:_______________________