UNIVERSITY OF THE EAST

Choice1
RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.
Ref. No.201904627
#64 Aurora Boulevard, Barangay Doña Imelda,
Appl. No.2020005147
Quezon City, 1113 Philippines
OR No._____________
Website: www.uerm.edu.ph • Trunkline: (+632) 8-715-0861 loc. 205
Date_____________

College of ALLIED HEALTH PROFESSIONS

APPLICATION FOR ADMISSION

Attach 2x2
For Academic year: 2020-2021
Picture
First Semester
B.S. IN MEDICAL TECHNOLOGY

Personal Information
Name: BALOCATING, ANNE NICOLE MENDOZA

Permanent Home
#24 NAZARENE ST. TIERRA VISTA SUBD. PARANG, MARIKINA CITY, 1809
Address:

Current Address: #24 NAZARENE ST. TIERRA VISTA SUBD. PARANG, MARIKINA CITY, 1809

Landline
Mobile Number: 09062003421 N/A Email: annenicolebalocating0103@gmail.com
Number:

Birthdate: 2002-01-03 Birthplace: MANDALUYONG CITY

Age: 18 Sex: F Citizenship: FILIPINO

Civil Status: SINGLE Religion: ROMAN CATHOLIC

Name of spouse: - Occupation: -

Parents

Father Mother

Name: ELVIS M. BALOCATING Name: NINA M. BALOCATING

Occupation: POLICE OFFICER Occupation: CUSTOMER SERVICE CONSULTANT

PHILIPPINE NATIONAL POLICE, CAMP 12F SOLARIS ONE BLDG. DELA ROSA ST. LEGASPI VILLAGE,
Office Address: Office Address:
CRAME, QUEZON CITY MAKATI CITY 1226

Contact Number: 09064728427 Contact Number: 09568273380

Email: N/A Email: ninadreamingstar@gmail.com

Are you a permanent resident of another country? NO

if yes, what country?

Permanent Home
#24 NAZARENE ST. TIERRA VISTA SUBD. PARANG, MARIKINA CITY
Address:

Provincial Address: N/A

Guardian (other than

NINA M. BALOCATING Occupation: CUSTOMER SERVICE CONSULTANT
parents):

Address: #24 NAZARENE ST. TIERRA VISTA SUBD. PARANG, MARIKINA CITY

Contact Number: 09568273380 Email: ninadreamingstar@gmail.com

Character References:

Name Address Contact Number

12 Tarpon St. Mira Verde, Nangka,

Mark Segui 09479947206
Marikina
*2020005147*
8 Bumblebee St. Greenbrier Vill., San
Alma Edones 09177991979
Mateo Rizal

33 Apitong St., Marikina

Adrian De Guzman 09155480603
Heights,Marikina City
Educational Information
Are you a college graduate of any foreign school? NO

What was the last school attended? N/A

Degree: B N/A,

Schools Attended:

Inclusive years:
Elementary: ST. SCHOLASTICAS ACADEMY OF MARIKINA
2007 - 2014

Address: 2 WEST DRIVE, MARIKINA HEIGHTS, MARIKINA CITY

Inclusive years:
Junior High: ST. SCHOLASTICAS ACADEMY OF MARIKINA
2014 - 2018

Address: 2 WEST DRIVE, MARIKINA HEIGHTS, MARIKINA CITY

Inclusive years:
Senior High: ST. SCHOLASTICAS ACADEMY OF MARIKINA
2018 - 2020

Address: 2 WEST DRIVE, MARIKINA HEIGHTS, MARIKINA CITY

Inclusive years:
College: N/A
N/A

Address: N/A

Honors / Awards Received:

N/A

Extra curricular activities in High School / College:

Sports Festival Bronze Medalist for Tug-O-War (Junior High grade 9), , Sports Festival Gold Medalist for Art Relay (Junior High grade 10), , Sports Festival
Silver Medalist for Kickball (Senior High grade 11)

Have you applied for admission to other school/s? NO

Name of school:

Status of application: UNDER PROCESS

Are you a child of a UERM Alumni? NO

MOTHER FATHER

Class: Class:

College: College:

Graduating with Honors? N/A

Financial Information
How do you plan to finance your education? Please indicate in percentage (%)

Your own resources: 0.00 Parents: 100.00 Other relatives: 0.00

Other sources (scholarships, PVA, special funds, etc.): 0.00

Combined annual income of parents: 720,000.00

*2020005147*
 SIGNED DECLARATION BY THE APPLICANT
1. I hereby certify that:
a. I have NOT withheld any information from this application that might prevent my admission.
b. I have PERSONALLY filled out this form and that to the best of my knowledge, all the information contained herein are
COMPLETE and ACCURATE.
c. I have NOT been debarred from other schools.
2. I hereby pledge that:
a. My enrolment will be automatically canceled if UERMMMCI finds out that I have provided false information or documents to support
my application for admission;
b. If admitted to UERMMMCI, I will comply with all the rules and regulations now in effect or which hereinafter may be formulated;
c. I will join only in campus organizations recognized by UERMMMCI.
3. I hereby agree and understand that this form and all documents submitted in support of my application for admission becomes the
property of UERMMMCI and will be retained and disposed of according to its retention and disposal policies.
4. If accepted, I hereby authorize UERMMMCI to publish my name in their bulletin board and/or websites for any relevant co-curricular and
academic issues/events.
5. I authorize UERMMMCI and its personnel to process all information I provided, including collecting, recording, organizing, storing,
retrieving, consolidating, sharing or using the information and/or documents provided in any other way necessary to pursue its legitimate
interests in relation to my application for admission. I understand that UERMMMCI may keep my information for historical and statistical
purposes.
6. I will voluntarily submit myself to an annual physical examination; I further understand that failure to do so in any school year during my
attendance in the university will result to my conditional enrolment, subject for completion within a period prescribed by UERMMMCI.
7. I understand that in relation to CHED Memorandum Order (CMO) No. 18 series of 2018, I will voluntarily submit myself to undergo
mandatory drug testing, if needed. I agree to shoulder any related cost that may arise in performing the mandatory drug testing, if not
funded by the government.

Signature over Printed name of Applicant Date Accomplished

Guardian's signature over Printed Name Date Accomplished

(If the applicant is minor)

*2020005147*
*2020005147*