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[2 x 2]
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taken within
two months

APPLICATION FOR ADMISSION

First Semester SY 2011 - 2012

1. NAME [Please print]_______________________________________________________________________________

(Surname)

(Given Name)

(Middle Name)

2. Permanent Address__________________________________________________ Tel. No._______________________

Mailing Address____________________________________________________ Tel. No._______________________
3. Date of Birth_________________________ 4. Place of Birth______________________________________________
5. Gender ____________________ 6. Height (cm)____________________ 7. Weight (kg)________________________
8. Civil Status_______________________ 9. Nationality & Citizenship_________________________________________
10. Educational Attainment:
Level of Education

A. HIGH SCHOOL

B. COLLEGE

Degree Earned
School/University
Address
Inclusive Dates
Honors Received

11. Fathers Name____________________________________________ Occupation_____________________________

12. Mothers Name____________________________________________ Occupation____________________________
13. Have you applied for admission to the Institute of Medicine, FEU-NRMF before?
[ ] No

[ ] Yes

What year?___________________________________

14. Have you been admitted into any medical school before?
[ ] No

[ ] Yes

Where & When?________________________________

15. How do you intend to finance your medical studies?

___________________________________________________________________________________________
___________________________________________________________________________________________

(Do not fill this block)

General Weighted Average________________________ Total No. of Failures___________________________
NMAT Score______________________________________ Interview Rating_______________________________
Remarks_________________________________________________________________________________________

NOTE: All information and documents asked for in this form should be submitted or
else this application will not be processed. False information will invalidate this
application and will result to immediate rejection of the applicant.
WARNING TO ALL APPLICANTS: Selection of students seeking admission into the
Institute of Medicine, FEU-DR. NICANOR REYES MEDICAL FOUNDATION , will be
based mainly on the criteria set for acceptance by the Admission Committee. No one
from inside nor outside the Medical Foundation can offer, much less buy, your
admission into this medical school. You will be accepted strictly on the basis of merit.
Please do not fall prey to unscrupulous impostors who will attempt to take advantage
of the innocence of some applicants by making false promises of admission in
exchange of money or other forms of material remunerations. The Admission
Committee definitely condemns such immoral acts and shall appreciate your reporting
to the Dean any knowledge you may have of it.
The Chairman and Member of the Admission Committee were chosen on the basis of
competence and integrity as well as their tremendous loyalty to the Medical
Foundation, so please refrain from approaching any of them.
IMPORTANT: Application and Processing Fee is Non-Refundable.
I hereby certify that I have read carefully all the foregoing and that if admitted, I shall abide by all the regulations and policies
formally promulgated by the FEU-Dr. Nicanor Reyes Medical Foundation.
_______________________________
Signature of Applicant
Received by:______________________ Date:___________________
Application Fee Receipt No._______________ Date______________________ Amount P__________________

FEU-DR. NICANOR REYES MEDICAL FOUNDATION

INSTITUTE OF MEDICINE

INFORMATION SHEET
DATE:_____________________________
APPLICATION NO:____________________
SURNAME:
FIRST NAME:
MIDDLE NAME:

Signature of Applicant
Date NMAT Taken:
Gender:

Male

Score:
Female

Date of Birth:

Nationality:

Civil Status:

City Address:
Cell No:
Permanent Address:
Course/Degree:
School:
Parent/Guardian:
Parent Occupation:
/jenm8-24-09:medicine appform & infosheet

Age:

Tel. No:
E-Mail Address:
Tel. No:
Year Graduated: