Application No.

:________________

WEST VISAYAS STATE UNIVERSITY

COLLEGE OF MEDICINE
Iloilo City

APPLICATION FOR ADMISSION

______________________________
(Date)
The Committee on Admissions
College of Medicine
West Visayas State University
Iloilo 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)
-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-

GUARDIANS / PARENTS 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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DEANS / REGISTRARS 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 UNIVERSITY

COLLEGE OF MEDICINE
Iloilo City

STUDENTS 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):____________________________

CERTIFICATION
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:_______________________