Medical Director‘s Office

U.N. Avenue corner Taft Avenue, Ermita, Manila

Tel. No. 523-81-31 to 64 MEDICAL STAFF APPLICATION FORM
DEPARTMENT OF   DATE OF APPLICATION      
MEMBERSHIP: ACTIVE VISITING COURTESY

I. PERSONAL
NAME  
(SURNAME) (FIRST NAME) (MIDDLE NAME)

BIRTHDATE       AGE       GENDER       CIVIL STATUS       RELIGION      
CITIZENSHIP       E-MAIL ADD.      
TELEPHONE NO.       CELLPHONE NO.      
ADDRESS      
FATHER’S NAME       OCCUPATION      
MOTHER’S NAME       OCCUPATION      
SPOUSE’S NAME       OCCUPATION      
IN CASE OF EMERGENCY, PLEASE NOTIFY:
     
(NAME) (ADDRESS) (CONTACT NUMBER)

II. EDUCATION BACKGROUND

LEVEL NAME OF SCHOOL/HOSPITAL/INSTITUTION DATE
FELLOWSHIP            
RESIDENCY            
INTERNSHIP            
MEDICAL EDUCATION            
PREMEDICAL EDUCATION            
HIGH SCHOOL            
ELEMENTARY           

III. SPECIALTY BOARD CERTIFICATION (LOCAL & ABROAD)

SPECIALTY BOARD CERTIFICATION DATE OBTAINED
           
           

IV. ORGANIZATION MEMBERSHIP

     
     

V. (2) REFERENCES
NAME POSITION CONTACT NUMBER
                 
                 

VI. PROFESSIONAL DATA

Have you been terminated as member of the medical staff in any other hospital?      
Do you have any criminal or medico-legal case or charge filed against you?      
PRC #       SSS #      
TIN #       PHILHEALTH ACCREDITATION #   

APPLICANT’S STATEMENT
In this application, I declare that I have read and am willing to comply with the rules, regulations and policies of
Medical Center Manila (MCM) – Hospital Management Services, Inc. (HMSI) and the MCM Medical Staff Organization and I
accept the prescribed disciplinary action for violations of these institution’s and organization’s rules, regulations and policies.

SIGNATURE(Please refrain from signing beyond the box)

MCM\Forms-ADHO-007 Rev.00 06/21/13