COLLEGE OF MEDICINE

University of the Philippines

Manila

PRIMER ON THE
REGIONALIZATION
PROGRAM
Annex to the Acceptance to Serve
and
Assumption of Liability (ASAL)
Agreement
Academic Year 2015-2016

TABLE OF CONTENTS
Part I
Vision-Mission-Goals of the UPCM
The Regionalization Program (RP)
- Historical Background
- Scheme
- Who May Apply to the RP
- Application Procedures

Page
1
2
3
4
5

Part II
Implementing Rules & Regulations
Rule

I
II
III
IV
V
VI
VII
VIII
IX
X
XI

Inclusion Criteria
Obligations of Medical RP
Students
Return Service
Coordinating, Monitoring
Evaluation and Placement
Pre-Termination and
Penalties for Breach of
Obligations
Student Records Prior to
Completion of Return Service
Arbitration Committee/
Proceedings
Dispute Settlement
Terms of Payment
Effectivity
Amendments

8
9
10
11
12
13
14
15
16
16
16

Part III

ASAL Agreement

17

Part IV
Suretyship Agreement

21

Reply Slip
Glossary
Officers of Administration
The Regionalization Program Committee

23
25

VISION, MISSION AND GOALS

OF THE
COLLEGE OF MEDICINE
VISION
A community of scholars
highly competent in the field of medicine with a heightened
social consciousness;
imbued with moral, ethical and spiritual vigor;
dedicated to a life of learning;
committed to the development of Philippine society;
inspired by love, compassion and respect for the dignity of
human life, and anchored on the principles of Truth, Freedom,
Justice, Love of country and the Democratic way of life.
MISSION
Guided by moral, ethical and spiritual values, we commit ourselves to
excellence and leadership in community-oriented medical education, research
and service, using the primary health care approach, intended especially for
the underserved.
SUMMARY MISSION STATEMENT
T owards L eadership and Excellence in Com m unity-Oriented Medical
Education Directed to the Underserved.
UPCM VISION
The UPCM shall be:
1. A Center of Excellence for graduate medical education in
the country;
2. A leading medical school in the ASEAN region;
3. A recognized medical institution in the global community.
Committed to produce excellent and socially responsible doctors in the
Philippines, especially in underserved areas.

The REGIONALIZATION PROGRAM

Historical background
The University of the Philippines Manila, College of Medicine
(UPM
-CM) and its teaching hospital, the Philippine General Hospital (PGH)
are institutions that are heavily supported by the government. The Filipino tax payers subsidize the medical education of its students. In return, medical graduates of the UPM-CM must therefore perform a role
that is relevant to national development in a way that its unique resources enable it, even mandate it to accomplish.
In the past, majority of students admitted to the UPM-CM and who
eventually graduated came from the National Capital Region (NCR)
resulting in the inequitable distribution of medical graduates in the various regions of the country. The Admissions Committee of the
College in 1979 under then, Dean Gloria Aragon took on the challenge to
address this inequity by proposing the creation of the Regionalization
Program. It was in 1984 under the term of Dean Alberto Romualdez
when the Regionalization Program was approved by the College and the
University System as a category for admission to the UPM-CM. The
program was implemented the following school year of 1985-1986.
Initially, only five regions were included in the program but this
eventually involved every region of the country including the ARMM
and the CAR. Even in it its inception, there was already a recommendation to formulate a contract with the recipients of the program that stipulates that the graduates will serve their regions for an equal number of
years of their medical education. Failure to do so will mean that the
graduates will reimburse the College the amount spent for their
education.

Through the years, a social contract to serve the country was formulated
and signed by the student and the College, but full compliance to the
contract is yet to be achieved. In 2005, the Regionalization Program
Committee (RPC) deemed it necessary to bind the students in the
Program through a legal contract to serve his/her region for an equal
number of years of his/her medical education. The Acceptance to Serve
and Assumption of Liability Agreement (ASAL), a legally binding
contract to serve the country was implemented beginning academic
school year 2005-2006. Members of the Regionalization Program of the
graduating Class 2010 are the first UPM-CM graduates under ASAL
Agreement.
2

The SCHEME
Regionalization is a ter m used in r efer ence to a scheme that
would involve the acceptance of candidates from the various
regions of the country deemed to be in need of doctors . These
candidates will be the future leaders, experts and educators upon
their return to these areas.
Candidates for admission to the UP Manila College of Medicine
should signify their intention to be considered for the
Regionalization Program upon submission of their application
form. The candidates will then be oriented with regard to the
essence, goals and requirements of the program.
Before acceptance to the Program, the applicant is required to sign
a legally binding contract, signifying service to the Philippines,
after graduation, with his/her parent(s)/guardian(s) as cosignatories.

WHO MAY APPLY TO THE REGIONALIZATION

PROGRAM (RP)
1.

She/He must fulfill the minimum requirements of the

College of Medicine for admission

2.

She/He must show proof of residency in the community by

submitting the following:
a)
b)
c)

ITR of parents
Barangay Certification,
Certification of Membership of Indigenous People

3.

She/He must speak the dialect of her/his region.

4.

Preferably a graduate of the local elementary, high school

and/or college (Form 137 as proof, preferred but NOT
required)

5.

Preferably has participated in projects in her/his community

of origin certified by representatives of the organizations
involved (preferred but not required)

6.

She/He must be willing to sign a binding contract upon

application, signifying that she/he is willing to serve in her/
his community after graduation. The candidate's
parent(s)/guardian(s) must be co-signatories in the contract.

Once a candidate has signified her/his intention to be considered

under the UPCM-RP and is accepted to the College of Medicine,
she/he will have to meet all the obligations for all candidates to the
Regionalization Program and she/he will be given all the benefits
for being a part of the Regionalization Program.

APPLICATION PROCEDURES
1. Secure Forms from the Admissions Office of the UPCM upon payment of application fees:
a. Regionalization Program (RP) application form
(this will be given to the applicant together with the
Regular application Form)
b. Directory of the Community Liaison Officer (CLO) of
your region.
2. Contact the regional CLO for your interview appointment.
Submit Application Form together with the complete
requirements to the CLO & to the UPCM Admissions Office.
3.

List of requirements to be submitted to:

3.1. CLO
a. RP Application Form
b. NSO Birth Certificate
c. RP Form # 3 (to be provided by the A dmissions
Office)
d. True copies of Income Tax Return (ITR) of
parents for the last three (3) years
e. Voter's/Comelec ID of parent(s) and applicant
f. Letter of Intention addressed to the RPC Chair to
be considered under the Regionalization Program
and to serve the region (specific province) or
underserved regions of the Philippines after
graduation from medical school.

3.2. UPCM
a.
b.
c.
d.
e.
f.

Photocopies of all requirements submitted to CLO

Regular Application Form
Transcript of Records
NMAT Result
4 copies 2 x 2 pictures
3 copies of Acceptance to Serve and Assumption of
Liability (ASAL) & Suretyship Agreements
g. For Members of Indigenous People Group (IP):
A certification obtained from the National Commission
on Indigenous People
h. Certificate of participation in community projects
from representative of local organization (if any)
i. Reply Slip (page 23 of this primer)

4. Pass and qualify under the NMAT and GWAG Cut-off.

5. Be interviewed and evaluated by the members of the
Regionalization Program Committee (RPC) and the UPCM
Admissions Committee.
6. Await notification to see the Chairman of the RPC
Please also refer to Admissions Brochure ENTRANCE
REQUIREMENTS, GUIDELINES AND POLICIES ON
ADMISSION leading to the Degr ee of Doctor of Medicine
which is available at the Admissions Office.

PART II

The Implementing Rules and

Regulations (IRR)
and the
Acceptance to Serve
and Assumption of Liability (ASAL)
Agreement

RULE I
INCLUSION CRITERIA
Section 1: All candidates for admission to the UPCM-RP have 3
absolute admission requirements:
1. General Weighted Average Grade (GWAG) of at least
2.5000
2. National Admission Test (NMAT) score of 90th
percentile or better
3. Signed Acceptance to Serve and Assumption of
Liability (ASAL) Agreement
Section 2: All candidates for admission to the UPCM who signified
their intention to be considered for the Regionalization Program (RP)
written on their Application Form and who, upon application, have
been oriented with regard to the essence, goals, and requirements of
the program, are required to sign a legally binding contract. The ASAL
(Acceptance to Serve and Assumption of Liability) Agreement binds
the student to render service in an identified underserved locality in the
Philippines, after graduation. Parent(s)/guardian(s) are made cosignatories to the ASAL. The affixing of the parents & students
signatures is the last step towards acceptance to the UPCM .
Said candidates are considered RP applicants even if they also
signified their additional intention of being considered in the other
entrance categories.
Section 3: To be considered for and later included in the RP, the
applicant shall:

1. Tick the RP box in the application form, regardless of

their having signified any additional intention to be
considered in the other entrance categories;
2. Sign the ASAL and Suretyship Agreement forms that
are later notarized, prior to official admission to the
University

Section 4: The student shall thereafter execute/sign the ASAL

Agreement as a prerequisite for his/her inclusion in the official
class list for the semester. Official admission to the University
occurs at the time of issuance of the class list for each semester.
RULE II
OBLIGATIONS OF MEDICAL RP STUDENTS
Section 1: The UPCM RP student shall fully comply with the
following obligations:
Prior to graduation, by his/her faithfully adhering to the VisionMission of the UPCM by:
1. Participating in UPCM RP activities;
2. Participating in UPCM summer immersion activities.
Community Immersion in the Philippines is a prerequisite for
Off-campus elective;
3. Finishing the full prescribed years of medical college
education; and,
4. Obtaining a certification of satisfactory completion of the RP
from the Chair of the UPCM RP Committee (UPCM RPC) and
of an Exit Interview given by the UPCM RPC.
Failure to obtain a Certificate of Completion of the Regionalization Program
is not a disqualifying criteria for graduation but shall be merely considered
a breach of the ASAL Agreement subject to the prescribed penalties
imposed on said Agreement.

RULE III
RETURN SERVICE
Section 1: Immediately after graduation, the UPCM RP student shall:
1.
2.

Obtain a Philippine medical license

Practice full time in the underserved health
sector in any capacity as a physician for a
minimum of five (5) years; and
3. Undergo residency or post-graduate training in his/
her own region or other underserved areas in the
Philippines:
Provided, that, if residency or Postgraduate
training is done in Metro Manila or the National Capital
Region (NCR), such period spent shall not be counted as part of the return service;
Provided, further, that the RP student must
render service to the Philippines, before taking any
residency or post-graduate training in countries outside
the Philippines; and,
Provided, finally, that eligible postgraduate
training shall not include other undergraduate degrees
such as nursing.
Section 2: The UPCM RP student shall submit to the PGIM
Coordinating and Placement Office (CPO) on or before 31 December
of every year until completion of five (5) year return service beginning
the year he/she graduated from UPCM, a report of his/her health care
activities and proof of such services for that year, specifying the following minimum required information:
1.
2.
3.
4.

Exact location and address where he/she is

currently working
Nature of his/her work
The community served
Career plans/ goals for the succeeding year

10

Section 3: The return service shall be completed within 10 years from date
of graduation after which a cer tification of completion of r etur n
ser vice is issued.
Section 4: The failure of the UPCM RP graduate to inform the UPCM PGIM
office of his/her whereabouts and the completion of his/her return service
contract shall be considered a breach of the ASAL agreement and is subject
to the prescribed sanctions hereinafter provided.
RULE IV

COORDINATING, MONITORING, EVALUATION

AND PLACEMENT
A Coordinating and Placement Office (CPO) under the Post Graduate Institute of Medicine (PGIM) shall be established. This will ensure incorporation of updates/enhancements or additional recommendations from stakeholders and lessons from local and
international
examples into the
ACCEPTANCE TO SERVE AND ASSUMPTION OF LIABILITY
(ASAL) AGREEMENT.

This shall ensure choice of placement of UPCM RP graduates.

This will guarantee monitoring of the return service obligation collation of
the yearly written reports of the RP graduates to commence a year after official close of internship and validate the reports which include activities of
the previous year e.g. by employer or Local Government Unit (LGU). (DTI
forms if in private practice).

11

RULE V
PRE-TERMINATION AND PENALTIES FOR
BREACH OF OBLIGATIONS
Section I: Pre-termination of this Agreement may be allowed under
certain conditions, but in other/different conditions the same may be subject to prescribed penalties, as follows:
1.

Physical and mental incapacity of a permanent nature which

exceeds the Maximum Residency Rule (MRR) period and or leads
to release from the University, shall release the student from any
legal and financial liability.

Pre-termination due to physical or mental incapacity of permanent

nature entails no penalty.
2.

Physical and mental incapacity of a temporary nature which does

not exceed the MRR period and or does not lead to release from
the University upon decision/request by the Arbitration Committee
of the UPCM RP student, shall entail a payback scheme equivalent
to the number of years that the student took his/her medical course.

(Physical or mental incapacity of a temporary nature that resolves prior to

the lapse of the MRR period shall entail an extension of the period to
complete medical education and/or satisfy ASAL Agreement requirements.)
Section 2: Pre-termination due to non-completion of medical education due
to academic deficiencies shall entail a payback equivalent to the number of
years that the student was enrolled.

Section 3: Pre-termination due to dismissal of the student for disciplinary

action shall entail a payback equivalent to five (5) years of medical
education regardless of number of years completed.

12

Section 4: Pre-termination for any reason other than the ones above
enumerated shall entail a payback equivalent to five (5) years of medical
education regardless of number of years completed.
If the UPCM RP student fails to comply with his/her obligations under the
ASAL Agreement, upon the students request from UPCM for required
original transcripts of grades and/or diploma for out of the country
education/ job placement, the student may not be given a letter of
recommendation by the Dean. The transcript of
records and/or
diploma shall contain a statement about the student having been admitted
under RP, and his/her having reneged the corresponding obligation of a
return service.
RULE VI
STUDENT RECORDS PRIOR TO COMPLETION
OF RETURN SERVICE
1.

Transcript of Records requested before the completion of return

service shall bear the statement Subject to compliance with the
Return Service Agreement. Valid for employment within the
Philippines only.

2.

Request for authentication of medical education records from

hospitals/institutions abroad shall be denied.

3.

Request for Deans Letter of Recommendation for out of the

country education/training shall be denied.

4.

Request for UPCM Faculty to give letters of recommendation for

training abroad shall likewise be denied.

13

RULE VII

ARBITRATION COMMITTEE/PROCEEDINGS
Section I:
There shall be an Arbitration Committee whose
functions shall be to determine whether a UPCM RP recipient:
1. Has successfully completed his/ her obligations according to the
ASAL agreement, or
2. Has valid or non-valid reason not to be able to serve the
Philippines after graduation.
3. Committee decisions will be submitted to the Dean for
approval, and recommendation to the Chancellor.
Section 2: The Arbitration Committee shall be composed of the UP
Manila Legal Counsel and the following:
1. UPCM Assoc. Dean for Faculty & Students or his/her
representative
12
2. The UPCM Regionalization Program Committee Chair
3. The UPCM College Secretary
4. The UPCM RSO Student representative
The Chair shall be appointed by the Dean.
Section 3: Penalties due to breach of the ASAL Agreement and/or
Suretyship Agreement shall be settled through the Arbitration
Committee for any dispute in the implementation thereof. The Dean
shall report to the College Council, the names of the UPCM RP students
who satisfactorily fulfilled their ASAL Agreement obligations, those
who reneged, and the status of arbitration proceedings as well as the
arbitration agreements reached.

14

RULE VIII

DISPUTE SETTLEMENT
Section 1: In case of a dispute between the Parties arising from the
breach by the UPCM RP Student of his/ her obligations under ASAL
Agreement, the Parties agree to freely and voluntarily submit themselves
to the necessary consultation and negotiation for purposes of amicably
settling the dispute.
Section 2: Should the Parties fail to reach an amicable settlement, any
dispute or controversy arising from this Agreement shall be submitted to
arbitration in accordance with Law (RA 9285). The competent courts of
Manila shall have jurisdiction over these cases if legal action is resorted
to.

15

RULE IX
TERMS OF PAYMENT
Section 1: In the event that the UPCM RP student shall not be able to honor his/her ASAL Agreement and is then subjected to monetary penalties,
payment as determined by the Arbitration Committee and as confirmed by
the UP Manila Chancellor shall be payable in cash or check in favor of the
University of the Philippines Manila College of Medicine.
Section 2: The terms of payment if not paid in full can be negotiated with
the Arbitration Committee subject to the imposition of the official year on
inflation rate, during the period of payment and shall be reflected in a
promissory agreement to be entered into by UP Manila and the UPCM RP
student.
RULE X
EFFECTIVITY
Section 1: This IRR for the ASAL Agreement is effective for RP
entering UPCM starting Academic Year 2005-2006.

students

RULE XI
AMENDMENTS
Amendments to this IRR shall be subject to approval by the UP Manila
Chancellor upon the recommendation by the UPCM Dean.

16

Part III
ACCEPTANCE TO SERVE AND ASSUMPTION OF LIABILITY
(ASAL) AGREEMENT
This Acceptance to Serve and Assumption of Liability Agreement
(ASAL Agreement) made and executed this ______ day of
____________________ in ______________________, Philippines by
and between:
(name of student), Filipino, of legal age ,single/married to
_________________________, with residence and postal address at
________(address)__________________________ , hereinafter referred
to as Student;
- and University of the Philippines Manila College of Medicine,
with principal office at Pedro Gil St., Ermita, Manila, herein represented by its
Chancellor, ________________________________, hereinafter referred
to as UPCM;
WITNESSETH: That

WHEREAS, the Regionalization Program of the UPCM

hereinafter referred to as (the Program) strives to ensure excellence and
leadership in
community-oriented medical education, research and
service, using the primary health care approach, intended especially for
the underserved;
WHEREAS, the Student has applied to the Program and is aware
of the requirements of the said program, and for this purpose, the Primer
on the Regionalization Program is hereto attached as Annex A the same
to form an integral part hereof;
WHEREAS, the ASAL agreement becomes effective only upon
acceptance of the student to the College of Medicine;
WHEREAS, in consideration of his/her admission to the Program
and his/her being covered/under the abovementioned Agreement and
considering his/her availment of state subsidy for his/her tuition fees, the
student is required by UPCM to render health care services in his/her
region (specific province) or other underserved
regions of the
Philippines, immediately after his/her graduation;
17

NOW, THEREFORE, in
consider ation of the for egoing
premises, the Parties agree as follows:
Article I. Obligations of the Student
The Student, having been accepted into the Regionalization
Program (the Program) of the UPCM and covered by/under the ASAL
Agreement shall:
1. Faithfully adhere to the Vision-Mission of the UPCM specifically
the ideals and requirements of the Program;

2. Abide by the prescribed course or instruction unless sooner

separated or dismissed by competent authority for failure to cope
with the academic and/or disciplinary standards, rules and
regulations;
3. Render health care services in his/her region (specific province) or
other underserved regions of the Philippines, immediately after
graduation, for a minimum of five (5) years unless unable to do
so due to physical and/or mental incapacitations as determined by
UPCM authority;
4.

Submit on or before December 31 of every year for five (5) years,

beginning the year he/she graduated from UPCM, a report of his/
her health care activities and services for that year, specifying the
following minimum required information: (1) exact location
and address where he/she is currently working; (2) nature of his/
her work; (3) the community served; and (4) career plans/goals for
the succeeding year.
Article II. Penalty for Breach

1. The student acknowledges and agrees that before the

completion of his/her obligations under Article I of this Agreement and
such other obligations as may from time to time be imposed by concerned
University officials in the implementation of said Agreement, his/her
transcripts of grades and/or diploma shall bear the statement Subject to
compliance with the Return Service agreement. Valid for employment
within the Philippines only.
18

2. In addition, the Student shall be held liable for breach of contract

jointly and severally with his/her parents or guardians, and guarantor/surety
as provided for in the Suretyship Agreement hereto attached as Annex C,
and reimburse to UPCM twice the full amount of his/her tuition,
government subsidy and scholarship, and all other expenses incurred by
UPCM during his/her entire period of schooling as a student of the Program,
with interest at the prevailing legal rate at the time of the breach of the
aforesaid ASAL Agreement, in the event that he/she shall fail to fulfill the
above mentioned obligation in paragraphs 3 and 4 of Article I, for no justifiable reason as determined solely by UPCM authority.
3. The College of Medicine, UP Manila reserves the right to
determine the amount to be paid back based on the fair financial liability of a
student who reneged on the Agreement subject to the estimated amount of
subsidy consumed plus other relevant costs and inflation from the
perspective of the government.
Article III. Free and Hold Harmless Clause
Any loss and/or damage caused by the Student to any person as a
result of his/her performance of health care services as required under this
ASAL Agreement shall be the sole and exclusive liability and responsibility
of the student. In this connection, the Student holds UPCM free and
harmless from all claims, liabilities, proceedings, damages, costs, charges
and expenses whatsoever arising out of or as a result of such loss and/or
damage.
Article IV. Alternative Dispute Resolution
In case of a dispute between the Parties, arising from the breach by
the Student of his/her obligations under this ASAL Agreement, they hereby agree to freely and voluntarily submit themselves to the necessary consultation and negotiation for purposes of amicably settling their dispute.
Should the Parties fail to reach an amicable settlement, any dispute or
controversy arising from this Agreement shall be submitted to arbitration, in
accordance with law (RA 9285). Finally, the Parties agree that should their
dispute reach the courts of law, the competent courts of Manila shall have
exclusive jurisdiction over the same.

IN WITNESS WHEREOF, the Par ties her eto her eby sign this ASAL
Agreement
together with the parent(s)/guardian(s) of the Student, this ____ day
of ________________ at __________________, Philippines.
_________________________
Name and Signature of Student

_____________________________
Chancellor, UP Manila

_________________________
Name and Signature of Mother

_____________________________
Name and Signature of Father

Signed in the presence of:

_________________________
_____________________________
Signature over printed name
Dean, UPCM
of witness
ACKNOWLEDGMENT
Republic of the Philippines)
________ , Metro Manila) s.s.
BEFORE ME, this ___
appeared:
Name
_________________________
_________________________

day of _______ in __________ personally

GOVT. ISSUED ID
______________
______________

ISSUANCE DETAILS
__________________
__________________

known to me and to me known to be the same persons who executed the foregoing
instrument and they acknowledged to me that the same is their free and voluntary
act and deed as well as that of the institution represented.
This instrument refers to an Acceptance to Serve and Assumption of
Liability (ASAL) agreement that consists of four (4) pages, including the page
whereon the acknowledgment is written.
WITNESS MY HAND AND NOTARIAL SEAL, on the date and place
above written.
Doc. No.
Page No.
Book No.
Series of

_____________
_____________
_____________
_____________
20

Part IV
SURETYSHIP AGREEMENT
FOR UPCM REGIONALIZATION PROGRAM ASAL
This Agreement executed at ____________________ (place), on
______________ (date) by _________________________ (name of surety),
Filipino, of legal age, single/married to _____________________
with residence and postal address at ______________________________

hereinafter referred to as Surety, in

favor of the University of the
Philippines Manila College of Medicine, with pr incipal office at Pedr o
Gil St., Ermita, Manila, hereinafter referred to as UPCM;
WHEREAS, _________________________
(name of student)
(hereinafter referred to as Principal)
a student of the UPCM
Regionalization Program, executed the attached Acceptance to Serve and
Assumption of Liability Agreement (ASAL Agr eement) with UPCM
on _______________ (date of ASAL) to which this Surety Agreement is
attached to as Annex C
WHEREAS, UPCM r equir es that the due and faithful
performance of the provisions of the said ASAL Agreement be
underwritten by a Surety;
NOW, THEREFORE, for and in consider ation of the for egoing, the undersigned Surety, jointly and severally with the Principal, hereby
guarantee and warrant to UPCM that the Principal shall comply with and
perform all the stipulations contained in the ASAL Agreement, and that if
for any reason the Principal fails to comply therewith, the Surety binds himself jointly and severally with the Principal:
To reimburse the UPCM twice the full of such amount/s as may
have been defrayed for the Principals tuition, government subsidy and
scholarship, and all other expenses incurred by the UPCM, with interest
at the prevailing legal rate at the time of the breach of the aforesaid
ASAL Agreement.

21

The liability of the Surety under this Agreement shall be solidary, direct
and immediate and not contingent upon the enforcement by UPCM of whatever
remedies it may have against the Principal, and the Surety shall at anytime on
demand, pay to the UPCM whatever amount is owing from the Principal to the
UPCM to the extent stated above.
This instrument is intended to be a complete and free indemnity to
UPCM for any indebtedness or liability of the Principal arising from the ASAL
Agreement. It shall be valid and binding without further notice to the Surety,
until the Principal has complied with all his/her obligations under the said ASAL
Agreement.
IN WITNESS WHEREOF, the Sur ety has caused its author ized
representative to set his/her hand this ___ day of _________, 200__, in
___________________._______________________
___________________________
SURETY

______________________________
SPOUSE (if married)

Signed in the presence of:

_________________________
Signature over printed name

_____________________________
Signature over printed name
ACKNOWLEDGEMENT

Republic of the Philippines)

__________ Metro Manila) s.s.
BEFORE ME, this ______day of _______ in _________ per sonally
appeared:
Name
_________________________
_________________________

Govt. Issued ID
__________________
__________________

Issuance Details
________________
________________

known to me and to me known to be the same persons who executed the

foregoing instrument and they acknowledged to me that the same is their free and
voluntary act and deed as well as that of the corporation herein represented.
This instrument refers to as Suretyship Agreement for UPCM
Regionalization Program consists of two (2) pages, including the page whereon
the acknowledgement is written.
WITNESS MY HAND SEAL on the date and at the place first written
above.

22

Date: ______________________

____________________________________
Applicant

Signature over printed name:

23

______________________________
Guardian(s)

I certify that I have read and understood the policies and the Implementing Rules and Regulations (IRR) governing the
Acceptance To Serve and Assumption of Liability (ASAL) Agreement and for this pur pose, her eby manifest my acceptance and/or faithful adherence thereto.

Please submit together with your Application Form and other admissions requirements.
Incomplete application forms will not be accepted.
-----------------------------------------------------------------------------REPLY SLIP

GLOSSARY

ASAL
CM
CLO
CPO
DOH
IRR
IP
LGU
MRR
NMAT
PGIM
PRC
RP
RPC
RPAO
RPAA
RSO
UP
UPCM
UPM
UPMAS
UPMASA

Acceptance to Serve and Assumption of

Liability
College of Medicine
Community Liaison Officer
Coordinating and Placement Office
Department of Health
Implementing Rules and Regulations
Indigenous People
Local Government Unit
Maximum Residency Rule
National Medical Admission Test
Post Graduate Institute of Medicine
Professional Regulatory Commission
Regionalization Program
Regionalization Program Committee
Regionalization Program Alumni Organization
Regionalization Program Alumni Association
Regionalization Students Organization
University the Philippines
University of the Philippines College of Medicine
University of the Philippines Manila
University of the Philippines Medical Alumni
Society
University of the Philippines Medical Alumni
Society in America

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OFFICERS OF ADMINISTRATION
MANUEL B. AGULTO, MD
Chancellor, UP Manila
AGNES D. MEJIA, MD
Dean, College of Medicine
MARIA SALOME NICDAO-VIOS, MD
College Secretary

FRANCISCO P. TRANQUILINO, MD
Special Assistant to the Dean and
College Secretary

CORALIE THERESE D. DIMACALI, MD

Associate Dean for Academic Development

LEILANI S. APOSTOL-NICODEMUS,MD, MScFM

ARMANDO C. CRISOSTOMO, MD,MHPEd

Associate Dean for Planning & Research

RICARDO D.T. QUINTOS, MD, MSc, PhD

Assistant to the Associate Dean for Planning
& Research

MADELEINE W. SUMPAICO, MD
Associate Dean for Faculty & Students

LYNN CRISANTA D.R. PANGANIBAN,MD

Assistant to the Associate Dean for
Faculty & Students

LENORA C. FERNANDEZ, MD
Director, Postgraduate Institute of
Medicine (PGIM)

TERESA LUISA GLORIA-CRUZ, MD,MHPEd

Assistant to the PGIM Director

RAFAEL C. BUNDOC, MD
Assistant to the Dean for Alumni Affairs

RODY G. SY, MD
MELFRED L. HERNANDEZ, MD
Resource Generation Office

ANTHONY GERONIMO H. CORDERO, MD

ABDEL JEFFRI A. ABDULLA, MD
Return Service Obligation

LUCIA L. JUGUAN
Supervising Administrative Officer

Assistant to the Associate Dean for Academic

Development

REGIONALIZATION PROGRAM COMMITTEE

ABDEL JEFFRI A. ABDULLA, Chair & R egional A dviser, Region IX & A R M M
EDELINA P. DELA PAZ, MD, Vice-Chair & Regional Adviser, Region V
CORAZON A. NGELANGEL, MD
Region I & CAR

Members/Regional Advisers
JOAN TRILDE F. OCUBILLO, MD
Region VII & VIII

ROWENA F. GENUINO, MD
ARLENE A. SAMANIEGO, MD
Region II
ISIDRO C. SIA, MD
Region III & IV
CLEOTILDE H. HOW, MD
Region V
EDUARDO R. BAUTISTA, MD
MIRIAM JOY C. CALAGUAS, MD
SALVADOR BENJAMIN D. VISTA, MD

LEO D.P. CUBILLAN, ,MD

Region X & CARAGA
JOSEFINA ISIDRO-LAPEA, MD, MFM
Region XI
JOSE C. GONZALES, MD
Region XII
CHRISTIAN BONDOC Class 2017
Chair , Regionalization Students Organization (RSO)