(Given)
DAVAO MEDICAL SCHOOL
DMSF DRIVE, BAJADA, DAVAO CITY, FOUNDATION
PHILIPPINES
APPLICATION FOR ADMISSION
(Note: All items
TO THE must
FIRST be CLASS
YEAR filed out completely.
NAME OF Use typewriter of block print in ink)
APPLICANT (Family name)
Mailing Address
Tel.
Home Address
Tel
PERSONAL DATA
Age 22 Date of Birth April 18, 1988 Place of Birth Tulay zone II Jolo, Sulu
Sex Male Civil Status Single Religion Islam Citizenship (at birth) Filipino
Height (feet-inches) 5’6 ft. Weight (pounds) (now) _____________________
Medical History: Please list any illness(physical/mental) which may be considered serious and which you had within the
last 5 (Given)
years. Do you have any physical disability which might interfere with the practice of medicine?
(Middle)
Paste here a
___________________ YES NO. If Yes, please state. recent 2”x2”
Have you been convicted in court of any offense? ______ YES ______ NO. If YES, please explain,
______________________________________________________________________________________________. using additional
Photograph
sheets if necessary.
______________________________________________________________________________________________.
______________________________________________________________________________________________.
______________________________________________________________________________________________.
ABOUT YOUR FAMILY
Father’s Name Latip A. Hadjimuddin Mother’s Name Nur-ain A. Hadjimuddin
Occupation Police man Occupation House wife
Address Km2. Bhutan Indanan Jolo, Sulu Tel. No.
What is/are their source(s) of income?
_________________ Salaries __________________ Income from farm Others: ___________________
_________________ Commissions __________________ Income from rentals _________________________
_________________ Pension __________________ Income from business _________________________
Approximate total income of the Family ___________________ (Please include income of parents, unmarried
sisters and brothers, and income derived from the family enterprise.)
List down Family Assets
Hadjimuddin, Adzmar Arabani
______________________________________________________________________________________________
______________________________________________________________________________________________
How many brothers do you have? None How many sisters do you have? None
How many brothers are in high school? ____________ How many sisters are in high school? _________________
How many brothers areKm2. Bhutan Indanan
in college? Jolo, SuluHow many sisters are in college? _____________________
________________
Please state the courses your Please state09169298567
the courses your
Km2. Bhutan Indanan Jolo, Sulu
09169298567
brothers have completed or are
EDUCATIONAL
still taking BACKGROUND
________________________________________ School Attended
ELEMENTARY
________________________________________
SECONDARY
________________________________________
sisters have completed or are
still taking Location
______________________________________________ Dates
Have you earned academic honors in high school? ________________ YES _______________ NO
______________________________________________
Collegiate
If YESname
was itand Address of the
: _____________ School Granting
Valedictorian the
______________ DegreeFirst Honors Others ___________
______________________________________________
Degree Obtained BSBio
_____________ (Bachelor
Notre Dame of ofJolo
Salutatorian Science
Walled in Biology
______________ ) Honor _________________
Second Jolo, Sulu 1995-2002
Date
Afterof Graduation
finishing Citywere
March
high school 27, 2010
you enrolled in college courses in every subsequent semester until you
Have
earned you earned academic honors in college? _______________ YES _______________ NO
your
If YES,
BS/BA degree? please list: _________________________________________________________________________
_____________________ YES ______________________ NO
Notre Dame of Jolo High School Jolo, Sulu 2002-2005
Have If you taken and
NO, please state passed
why:the following subjects? If not, please see to it that you shall have taken all of them
____________________________________________________________________
Kasulutan
prior to ____________________________________________________________________
enrollment.
a. General Chemistry -5 units _______ i. Comparative Anatomy -5 units _______
b. Organic Chemistry -5 units _______ j. Physics I -5 units _______
c . College Algebra -3 units _______ k. Pilipino I & II * -6 units _______
d. Trigonometry -3 units _______ l. Phil. Gov’t Conts. * -3 units _______
e. Statistics -3 units _______ m. Land Reform & Taxation * -3 units _______
f. Zoology -5 units _______ n. P.E. (for female student) * -4 units _______
g. Botany -5 units _______ o. ROTC (for male student) * -6 units _______
h. Rizal * -3 units _______
* not required for foreign students
For those who did not proceed to Medicine proper immediately after graduation from college: what did you do
after
graduation?
________________ Took another course. Please list them with the school where they were taken, and when
________________ Worked as employee Medical Transcription in Brent Hospital and Colleges Inc.
________________ Worked in family business sch yr. 2010-2011
________________ Engaged in own business ____________________________________________________
________________ Stayed at home ____________________________________________________
Others ____________________________________________________
__________________
Other than academic subjects and routine activities, what other subjects or activities are you interested in, in a
more
than usual degree?
_______________ School organizations ______________ Music: vocal __________ Philately
_______________ Religious activities ______________ Music: instruments Others: ___________
_______________ Socio- civic action ______________ Classical/folk dance __________________
_______________ Sports ______________ Creative writing __________________
Please list down other skills or work experience that you have may be useful in the study/practice of
Giving first aid to an ill-person and taking vital signs were my skills and experiences during my college days. I also had an
medicine.
Is this your
experienced first cats
dissecting time tofrogs
and seekwadmission to theinDavao
hich I think useful studyingMedical
Medicine School
[Link]? ________
I also had an expe riencedYES ________
preserving andNO
makingIfslides
NO, ofstate when
a tissue was the first
in Histology. timeisyou
Sketching alsoapplied _________________________________________________
one of my skills that would also help me in visualizing the anatomy.
Is this your first time to seek admission to the medical course? ______________ YES ________________ NO
If NO, what happened to your application?
_________________ Accepted and enrolled at ___________________________________ (Name of medical school)
_________________ Accepted but did not enroll at _______________________________ (Name of medical school)
_________________ Application was not approved
ABOUT YOUR FUTURE PLANS:
How will your medical
_______________ Advice ofeducation
parents be supported?
_____________ Illness in family Others: ___________________
_________________
_______________ Parents
Advice ________________
of brother/sister _____________Approved Others ________________
Prestige of profession _________________________
What are your sources
_________________
_______________ Philof
Advice of information
Veteran
relatives about
Benefit this medical
________________
_____________ school?
Still
Awareness being processed
of health ______________________
_________________________
________________ Parents
_________________
_______________ of friends ________________
Scholarship
Advice _____________Brother/Sister
________________ Planning
Needs to apply________________Own
of community effort
______________________
________________ Family
Name of friends
Scholarship
_________________________ ________________
________________Teachers in college Others: _________________
________________ Friends who are ________________ Newspaper ad _______________________
________________ Students here ________________ Convocation _______________________
________________ Internet
If you will be studying here in Davao City, where will you most likely be staying?
_________________ At home, with parents Others: ________________________________________
_________________ At a boarding house/dormitory ________________________________________
_________________ At an apartment with relatives _________________________________________
_________________ At the house of relatives
Please list the medical school you have applied (or will apply) to for the coming school year, in the order of
your
preference:
First preference DMSF Other: ____________________________
Second preference ADZU ____________________________
Third preference________________________ __________________________
Do you have brother(s) or sister(s) enrolled in Davao Medical School Foundation? _________ YES __________ NO
If YES, please write their names : __________________________________________________________
__________________________________________________________
__________________________________________________________
I hereby certify on my word of honor that the
foregoing entries are true and correct to the best NOTE TO APPLICANT:
OF MY KNOWLEDGE. All communications pertaining to this application will be sent to
you at your mailing address. If you will not be at this address for
sometime, arrange for someone to transmit the communication to
you, or notify us for any change of address as soon as possible.
_________________________________
Signature of Applicant Send this application to :
OFFICE OF THE DEAN
Do not write in this space. Davao Medical School Foundation
Submit this application together with; Bajada, Davao City, Philippines
(a) One copy of the transcript of college records (for evaluation) which should include
P.O. Box 251 all course taken with
final Fax No. (082) 221-23-17
grades, except for those of the second semester of the current school year. drbasa@[Link]
EMAIL:
(b) Xerox copy of NMAT results. Website : [Link]
(c) Letter of reference from two former college teachers, or two prominent persons in your community who
can
vouch for your moral character. Please indicate their address.
(d) Remittance for the application fee.