NMAT

National Medical Admission Test

IDENTIFICATION (ID) FORM
(Must be SUBMITTED to the Examiner on the day of the test)

Application No.: 1031909775

SAMPATH, GAUTHAM
Bank Reference No.: 2571823915
Name of Applicant (name that will appear on your Answer Sheets and Examinee Report Form)
2000-12-12 Male India Single
Birthdate Sex Nationality Civil Status
University of the Visayas, Cebu City, Cebu
Name of College Graduating From
Cebu Philippines
2 X 2 ID Picture
State/Province of College Graduating From Country of College Graduating From
BS in Biology 2018-2019
College Course (Bachelors Degree) School Year Graduating

contact information
410 4TH FLR, 88 DORMITORY, BESIDE UV GULLAS NURSING OLLEGE, BANILAD, MANDAUE CITY, CEBU 6014 Philippines
Home Address
Test Center: Cebu City
410 4TH FLR, 88 DORMITORY, BESIDE UV GULLAS NURSING OLLEGE, BANILAD, MANDAUE CITY, CEBU 6014 Philippines
Test Date: March 10, 2019
Mailing Address
Results to be: Sent via postal mail
N/A +63-9227351437 sgautham1212@gmail.com
Test results and NMAT ID information released
to requesting medical schools? Yes Landline Mobile E-mail
(For Foreign Applicant only)
Medical School Choices:
1. University of the Visayas - Gullas College of Medicine Z4556861 July 04, 2028 CHENNAI
2. University of Northern Philippines - College of Medicine Passport No Expiry Date Place of Issue

3. Davao Medical School Foundation

FOR THE NMAT APPLICANT

1.  Bring this Form to your school. Your School Head must affix his/her signature on the space provided below to certify that you can graduate by the end of the
school year stated above.
2.  Bring this Form to the nearest Bank of the Philippine Islands (BPI) branch and pay the total of NMAT Registration and Test Fees (PhP________)
PHP1900.00 on or before
___________________
February 18, 2019 (Philippine Standard Time).
Copy the Bank Reference No. found on the upper left portion of this Form and CEM’s BPI account number 1881-0450-24 on the BPI Payment/
Deposit Slip. BPI may collect PhP30.00 - PhP50.00 as additional service charge.
3.  Check your email (including your spam mailbox) after two (2) business days for your payment confirmation email. You may also visit the NMAT website to verify
the status of your NMAT application and to download the NMAT Practice Set after payment has been confirmed.
4.  Visit the NMAT website two weeks before the test date to know your room assignment and to download your Examination Permit.
5.  Affix your signature on the certification below:

I hereby certify that I have read, fully understood, and accepted all the information, terms and conditions specified on the NMAT Bulletin of Information and on
the NMAT website www.cem-inc.org.ph/nmat, including, among others, the NMAT policies on refund of test fees, on cheating or improper test-taking behavior in
any manner or form, and on failure to take or complete the test on the test date and test center indicated on this Form. I further certify that all information I gave
on this Form is true and correct to the best of my knowledge and that any misinformation shall constitute grounds for my disqualification from taking the NMAT
or invalidation of my NMAT results.

Applicant’s Signature Date Signed

FOR THE SCHOOL HEAD

Please affix your signature on the space provided below to confirm the identity and academic status of the NMAT applicant.

I hereby certify that the person in the picture above can graduate from ________________________________________________________________
University of the Visayas, Cebu City, Cebu

with a college (bachelors) degree of/in ____________________________________________________________

BS in Biology by the end of school year ______________.
2018-2019
He/She can apply for admission to any Philippine medical college in the next schoolyear ________________.
2019-2020

Signature & Printed Name of School Head Designation Date Signed

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