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NMAT IDENTIFICATION (ID) FORM

National Medical Admission Test (Must be SUBMITTED to the Examiner on the day of the test)

Application No.: 1101704362


HERNANDEZ, MARIA ROXANNE
Bank Reference No.: 1752131956
Name of Applicant (name that will appear on your Answer Sheets and Examinee Report Form)
1985-08-10 Female Philippines Single
Birthdate Sex Nationality Civil Status
Our Lady of Fatima University - Quezon City, Quezon City, Metro Manila (NCR)
Name of College Graduated From
Metro Manila (NCR) Philippines
2 X 2 ID Picture
State/Province of College Graduated From Country of College Graduated From
BS in Nursing 2008-2009
College Course (Bachelors Degree) School Year Graduated

CONTACT INFORMATION
3233 BLDG 3 CLUSTER 2 ROOM 3-3 FLORAVISTA CONDOMINIUM PEACOCK STREET, FAIRVIEW, QUEZON CITY, METRO MANILA 1118
Philippines
Home Address
Test Center: Manila 3233 BLDG 3 CLUSTER 2 ROOM 3-3 FLORAVISTA CONDOMINIUM PEACOCK STREET, FAIRVIEW, QUEZON CITY, METRO MANILA 1118
Philippines
Test Date: October 22, 2017
Mailing Address
Results to be: Sent via postal mail
+63-29620341 +63-9985303116 mariaroxanneh@gmail.com
Test results and NMAT ID information released
to requesting medical schools? Yes Landline Mobile E-mail
(For FOREIGN APPLICANT only)
Medical School Choices:
1. University of the Philippines - College of Medicine
2. Pamantasan ng Lunsod ng Maynila - College of Medicine Passport No Expiry Date Place of Issue

3. University of the Philippines - School of Health Science

FOR THE NMAT APPLICANT


1. Bring this Form to the nearest Bank of the Philippine Islands (BPI) branch and pay the total of NMAT Registration and Test Fees (PhP________)
PHP1900.00 on or before
___________________.
September 22, 2017
Copy the Bank Reference No. found on the upper left portion of this Form and CEMs BPI account number 1881-0450-24 on the BPI Payment/
Deposit Slip. BPI may collect PhP30.00 - PhP50.00 as additional service charge.
2. Check your email (including your spam mailbox) after two (2) business days for your payment conrmation email. You may also visit the NMAT website to verify
the status of your NMAT application and to download the NMAT Practice Set after payment has been conrmed.
3. Visit the NMAT website two weeks before the test date to know your room assignment and to download your Examination Permit.
4. Afx your signature on the certication below:

I hereby certify that I have read, fully understood, and accepted all the information, terms and conditions specied on the NMAT Bulletin of Information and on
the NMAT website www.cem-inc.org.ph/nmat, including, among others, the NMAT policies on refund of test fees, on cheating or improper test-taking behavior in
any manner or form, and on failure to take or complete the test on the test date and test center indicated on this Form. I further certify that all information I gave
on this Form is true and correct to the best of my knowledge and that any misinformation shall constitute grounds for my disqualication from taking the NMAT
or invalidation of my NMAT results.

Applicants Signature Date Signed

Bring and submit also to your Examiner on the day of the test a photocopy of your ofcial
Transcript of Records (TOR) issued by the College where you graduated from. Your NMAT
results shall be WITHHELD indenitely if you fail to submit a photocopy of your TOR and/
or this NMAT ID Form.

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