Chinese General Hospital Colleges

286 Blumentritt St., Sta. Cruz, Manila 1014

Trunk Line Number: (632) 711-41-41 Local 601 / Telefax: (632) 711-00-75
Accounting Office: (632) 743-21-29 / Registrar‘s Office: (632) 743-89-41
College of Medicine Dean’s Office: (632) 711-00-75 Local 108 or 151

Application No. ______________

Paste here your recent 2x2

APPLICATION FORM FOR THE colored picture in white
background with complete
COLLEGE OF MEDICINE name tag at the lower
portion

PERSONAL INFORMATION

(Last Name) (First Name) (Middle Name)

AGE: _____ DATE OF BIRTH: _______________ PLACE OF BIRTH: ____________ CITIZENSHIP: ________________

GENDER: ___________ EMAIL ADDRESS: ________________________________________________________________

TELEPHONE No: ______________ MOBILE NUMBER: __________________________________________________

CURRENT ADDRESS: _________________________________________________________________________

PERMANENT ADDRESS: ______________________________________________________________________

MARITAL STATUS: ___________ NAME OF SPOUSE: _______________________ CITIZENSHIP: ________________

NAME OF FATHER: ___________________ PLACE OF BIRTH: ____________ CITIZENSHIP: _________ OCCUPATION: ____________

NAME OF MOTHER: ___________________ PLACE OF BIRTH: ____________ CITIZENSHIP: _________ OCCUPATION: ____________

PERSON & NUMBER TO CALL IN CASE OF EMERGENCY: _______________________________________________________

IF NATURALIZED FILIPINO CITIZEN, IDENTIFICATION CERTIFICATE NO._______________________________________

CERTIFICATE OF NATURALIZATION NO. ______________________ DATE OF ISSUE: _____________

IF I-CARD HOLDER, ACR SSRN: ___________________________ VISA TYPE: ____________________________

DATE ISSUED: ______________________ EXPIRY DATE/ VALID UNTIL: _______________________

HAVE YOU EVER BEEN CONVICTED OF A CRIME? _________________________________________

DO YOU ALREADY HAVE A SCHOLARSHIP / FINANCIAL AID MD COURSE? ________________________________

IF NOT, WHO WILL FINANCE YOUR MEDICAL EDUCATION? ________________________________________________

IMMEDIATE FAMILY MEMBERS (1o RELATIVES) WHO GRADUATED OR ARE ASSOCIATED WITH CGHC:
NAME RELATION CGH UNIT & STATUS YEAR
AT LEAST TWO CHARACTER REFERENCES (NON-RELATIVES)
NAME POSITION ADDRESS PHONE NUMBERS

EDUCATIONAL BACKGROUND

HIGH SCHOOL: _______________________________________ MONTH & YEAR GRADUATED: _____________________

ADDRESS: _______________________________________ ACADEMIC HONORS: _____________________________

COLLEGE: _________________________________________ COURSE: _____________________________________________

MONTH & YEAR GRADUATED (OR EXPECTED TO): ____________ GENERAL WEIGHTED AVERAGE: _________

ADDRESS: ___________________________________ ACADEMIC HONORS: ____________________________

HAVE YOU EVER BEEN EXPELLED/ DISHONORABLY DISCHARGED FROM A SCHOOL? _____________________

POST GRADUATE: ___________________________________________________________________________

ANY MEDICAL SCHOOL ATTENDED PRIOR? ________________________ MONTHS/ YRS COMPLETED _____________

NMAT SCORE: ___________ DATE TAKEN: ____________

_______________________________
NAME & SIGNATURE

* ANY INTENTIONAL FALSIFICATION OR MISREPRESENTATION OF INFORMATION ON THE APPLICATION FORM

OR ON SUPPORTING DOCUMENTS WILL BE GROUNDS FOR DISQUALIFYING THE APPLICANT.

GENERAL APPLICATION REQUIREMENTS:

 Accomplished application form. May do so online at http://www.cghc.edu.ph/
 Photocopy of PSA/NSO Birth Certificate; I-Card or ACR; Certificate of Naturalization
 Photocopy of Transcript of Records for at least the first three and a half years of a Baccalaureate Program.
 Certification from Dean that the applicant belongs to the Graduating class if the TOR is still incomplete
 Photocopy of NMAT Score (not more than 2 years from the time of expected admission)
 Recent 2x2 colored ID picture or scan with white background and complete name on the front

GENERAL ADMISSION REQUIREMENTS:

 Official receipt of application fee
 Original PSA/NSO Birth Certificate; Certified True Copy of I-Card or ACR or Certificate of Naturalization
 Certified True Copy of Transcript of Records for at least the first three and a half years of a Baccalaureate Program
 Certified True Copy of Diploma or Certificate of Graduation
 Original Certificate of Eligibility for Admission to Medical School from CHED
 Original certificates of good moral character from
1. the Dean, Office of Students’ Affairs, or Guidance Counselor of applicant’s school
2. a professor under whom the applicant was a student
 Original NBI Clearance
 Original Copy of NMAT Score (not more than 2 years from the time of expected admission)
 Passing a Complete Medical Examination by the College Physician
 Passing an Aptitude/ Entrance Exam
 Passing an Interview with the Admissions Committee
 Four (4) pieces of identical and recent 2x2 colored ID picture with white background and complete name on the front
 One (1) piece long plastic envelope
 Two (2) pieces long brown envelope