Professional Documents
Culture Documents
School of Medicine
Zamboanga City
O.R. No.
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PERSONAL DATA
Name _________________________________________________________ Nickname ______________
Last Name
First Name
Middle Name
Home Address:
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Age ___________
Educational Attainment
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EDUCATIONAL BACKGROUND
School
Elementary
Year Attended
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College
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OTHER INFORMATION
In a short paragraph, describe yourself and your social life.
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Describe briefly any hobbies, sports and special skill that you engage in and how involved you are with
them.
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Please check where appropriate:
Do you smoke?
( ) Yes
( ) No
Do you drink?
( ) Yes
( ) No
( ) Yes
( ) No
( ) Yes
( ) No
( ) Yes
( ) No
( ) Yes
( ) No
From whom did you learn about Ateneo de Zamboanga University School of Medicine?
( ) Newspaper
( ) Friend/Classmate
( ) Family Member
( ) Former Teacher
( ) Others __________________
Who? _______________________________________________________________
( ) No
Did they influence your own career choice?
( ) Yes
( ) No
( ) Relatives
( ) Scholarship
( ) Grant
Describe briefly any experience/training related to medicine you have had. Example: Red Cross
Volunteer Work, CPR, etc.
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Give a brief statement of whether you would or you would not enjoy staying in a rural community as a
student-doctor of the Ateneo de Zamboanga University School of Medicine
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Describe briefly your idea of a good doctor
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Do you expect to pursue further specialization in a certain field of medicine? Why?
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Applicants Signature