St. Dominic

School of Medicine Application Form

PERSONAL INFORMATION

First Name

Middle Name

Last Name

Birth Date

Birth Place

Gender

Nationality

Tel No.

Mobile Number

Email Address NOTE: Please enter an active email address.

Religion

Civil Status

Are you a member of a Culture Minority/Indigenous People Group

ADDRESS

Country

Province

City

Zip Code

House No.

Street

Subdivision

INFORMATION NEEDED TO APPLY TO SCHOOL OF MEDICINE

Is this the first time you are applying for admission to a medical school?

Are you concurrently applying for admission to medical school other than St. Dominic College of Asia's School of Medicine?

Ever Enrolled in a Medical School?

COLLEGE / UNIVERSITY

College / University

Year Graduated

GWA

Program

Major

School Address

Academic Honors Received:

SENIOR HIGHSCHOOL
*Only fill here if applicable, N/A if not applicable

School Name

Year Graduated

Track

Strand

School Address

SECONDARY / HIGH SCHOOL

School Name

Year Graduated

School Address

GRADE SCHOOL / ELEMENTARY

School Name

Year Graduated

School Address

TRANSFEREE / 2ND COURSER
*Only fill here if transferred from another school*

School Name

Last Year Attended

School Address

Course / Program

FAMILY INFORMATION

Parent Status:

Father's Name

Occupation

Address

Contact Number

Father's Email Address

Father's Income

Father's Education Level

Mother's Name

Mother_Occupation

Address

Contact Number

Mother's Email Address

Mother's Income

Mother's Education Level

GUARDIAN (if not living with parents)

. Guardian's Name

Relationship

Address

Contact Number

OTHER INFORMATION

How Did you know about SDCA?

Application

Walk In (Admissions Office)

Online (Outside SDCA)

(Optional) Do you have relatives in SDCA ? Employee Currently Enrolled

Name

Relationship

Course / Department

Contact Number

(Optional) Are you a beneficiary of the 4Ps program?
Yes No

Do you have any physical and/or mental condition/s that we should be aware of for your welfare? if not applicable please put N/A

if yes, please indicate here:

Course

Choice:

Program:

Program Code:

Applied School Year:

Applied Semester:

Character References

Please List 3 references who can be easily contacted by the Admissions Comittee. References should include two from the last school you attended and one from the community.

Name	Telephone No. / Contact Info	Address	Relationship

Requirements:

Checklist for the Required Documentation and information needed to apply to School of Medicine for Academic Year .

Original and Photocopy of Diploma or Certificate of Candidacy for Graduation of taken Bachelor's degree program.

If The Bachelor's Degree taken is a board course, a Board rating Certificate shall be required.

Original and Photocopy of Transcript of Records
Certificate of Good Moral Character issued by Student Affairs and its equivalent.
Two (2) Letters of Recommendation or Certificate of Recommendation from former Dean, Professor, Employment,and other government agencies (LGUs, etc)
Original and Photocopy of PSA Birth Certificate
3 pcs 2x2” Colored Picture (White Background with Name Tag)
Original and photocopy of NMAT result
If Member of Cultural Minority/Indigenous People Group, a Certification of Membership from:
Submission of accomplished health clearance report from school clinic (HSO) which shall include the following:
- Complete immunization report
- Laboratory Test including Urinalysis & Fecalysis
- Chest X-ray
- Drug Test
Certificate of Physical Fitness, to be issued by the physicians from St. Dominic College of Asia's HSO

School of Medicine Application Form

ABOUT COMPANY

SOCIAL LINKS

OUR LOCATION

Name
Birthday		Birth place
Gender		Nationality
Telephone		Cellphone
Email
Religion		Civil Status
Address

Country		Zip Code
Are you a member of a Culture Minority/Indigenous People Group ?		Office :

Parent Status
Father Information
Name		Occupation
Email Address		Contact Number
Address
Mother Information
Name		Occupation
Email Address		Contact Number
Address
Guardian Information
Name		Relationship
Address		Contact Number

Year Level
Applied School Year		Applied Semester
Choice
Program		Program Code

FIRST
Name		Contact
Relationship		Address
SECOND
Name		Contact
Relationship		Address
THIRD
Name		Contact
Relationship		Address