BICOL CHRISTIAN COLLEGE OF MEDICINE

Rizal Street, Legazpi City, Philippines

Tel. No. 820-58-77
“God Heals, We Serve”

APPLICATION FORM ADMISSION

Medicine Program
2x2 picture
Application No.:___________
O.R. No.__________________
Date:_____________________
NMAT:___________________

1. Name:______________________________________________________________________________________
(Family Name) (First Name) ( Middle Name)

Hereby applies for admission to the College of Medicine and submits hereunder facts as a true and correct statement of
his/her history education.
2. Age: _________ Sex:_______ Citizenship____________ Religion:_____________ Civil Status:_______________
3. If Married:
Name od Spouse:_________________________ Address:__________________________________________________
Occupation:____________________________________________ Tel. No.:____________________________________
4. Date of Birth:____________________________________ Place of Birth:________________________________
5. Permanent Home Address:_______________________________________ Tel. No.:_______________________
6. Temporary Address:_____________________________________________Tel. No.:_______________________
7. Parents:
Father:____________________________________ Occupation:______________ Tel. No.__________________
Address:____________________________________________________________________________________
___________________________________________________________________________________________

Mother:___________________________________ Occupation:______________ Tel. No.__________________

Address:____________________________________________________________________________________
___________________________________________________________________________________________

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:

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

8. Education:

SCHOOL ATTENDED SCHOOL YEAR

Secondary: _______________________________ ________________

College:
1st Year__________________________ _________________
2nd Year__________________________ ________________
3rd Year __________________________ ________________
th
4 Year __________________________ ________________
5th Year __________________________ _________________
Degree________________________________________ Date graduated _______________________

9. Other Collegiate taken (Degree if any): Where and when taken:

_______________________________________________________________________________________
_______________________________________________________________________________________

10. Have you applied for admission to any other Medical School?_____________ if so what Medical School
and what is the status of your application:__________________________________________________
 ____________________________________________________________________________________

11. Have you studied in any College of Medicine?_____________if yes, where and when?______________
____________________________________________________________________________________

12. Employment and/or any other pursuit, past and

present_______________________________________
____________________________________________________________________________________
_

13. State any additional information concerning yourself which you believe might be useful to the
COMMITTEE ON ADMISSION in evaluating your application, (College, honors, membership in societies,
Athletics, College Publications, Student Government, School Organization and any extra activities in
School)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______

14. I fully understand that among other requirements to be satisfied for admission to the College of
Medicine (AMEC-BCCM)
15. I HEREBY PLEDGE that If admitted to the College of Medicine, BCCM, I shall comply with the rules of
the College now in effect which hereinafter may be formulated.

My enrolment will be automatically cancelled, If I have enrolled under FALSE PRETENSESES, such as the
use of irregular credentials, being debarred from re-admission for reason of poor scholastic standing or
for disciplinary action and my graduation in due time depends, not only in the completion of academic
requirements, but also on the required credits.

_____________________________
Signature over printed name of applicant