PGH Form No.
A-310006
PHILIPPINE GENERAL HOSPITAL
The National University Hospital
University of the Philippines Manila
Taft Avenue, Manila
PHIC-Accredited Health Care Provider
ISO 900:2008 Certified
APPLICATION FORM FOR RESIDENCY/POST-RESIDENCY FELLOWSHIP
NAME __________________________________________ AGE ______ SEX _____ CIVIL STATUS________
IF MARRIED, MAIDEN NAME __________________________ NAME OF SPOUSE_____________________
DATE OF BIRTH_______________________________ PLACE OF BIRTH ____________________________
CITIZENSHIP Filipino Dual If yes, by birth by naturalization
Pls indicate country if not Filipino________________________
ADDRESS: CITY __________________________________________ PROVINCE _____________________
TELEPHONE NO. ____________CELLPHONE NO. _______________e-MAIL ADDRESS ________________
FATHER _______________________________________ MOTHER _________________________________
POSITION APPLIED FOR: [ ] RESIDENCY [ ] POST-RESIDENCY FELLOWSHIP
A. SPECIALTY:
( ) Anesthesiology ( ) Medicine ( ) Ophthalmology ( ) Radiology
( ) Dermatology ( ) Neurosciences ( ) Orthopedics ( ) ___________
( ) Emergency Medicine ( ) Neurology ( ) Otorhinolaryngology ( ) Rehab Med
( ) Family & Community Medicine ( ) Neurosurgery ( ) Pediatrics ( ) Surgery
( ) Laboratories ( ) Obstetrics & Gynecology ( ) Psychiatry ( ) ___________
( ) Toxicology
B. SUBSPECIALTY: _____________________________
EDUCATIONAL BACKGROUND
Level Degree Name of School Year Graduated
College (Pre-Med)
Medicine
Other Post-
Graduate Studies
WORK EXPERIENCES/HOSPITAL AFFILIATIONS
Internship _________________________________________________ Year Completed ___________
Residency (Specify) _________________________________________ Inclusive dates ____________
Others (Specify) ____________________________________________ Inclusive dates ____________
____________________________________________ Inclusive dates ____________
HONORS/AWARDS/RECOGNITION RECEIVED:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
REFERENCES (Name) (Address) (Telephone)
1. _______________________________________________________________________________
2. _______________________________________________________________________________
Signature ___________________________________ Date ________________
(Required documents – see back page)
REQUIRED DOCUMENTS:
______1. 1 pc. 2”x2” picture (not more than 1 year)
______2. Copy of certification of class rank and general weighted average grad (GWAG) from the Office of the
Dean/Office of the Registrar (original or certified true copy)
______3. Proof of payment of application fee (PhP 300)
______4. Xerox copy of the following (1 copy each)
________a. Transcript of Records
________b. M.D. Diploma
________c. PRC Board Rating
________d. Certificate of Internship
________e. Certificate of Residency, if applying for Post-Residency Fellowship
NOTE: Application forms and requirements should be submitted thru the:
1) Office of the Deputy Director for Health Operations (hard copies)
2) Soft copies MAY BE submitted thru the Department email addresses
Please Include a copy of the proof of payment of the application fee (PhP300) in the submission.
Payments can be made thru PGH Cashier or thru bank deposit DBP-PGH
(UPM-PGH Revolving Fund Acct # 00005-029-410-4 (only possible if fund transferred from
Metrobank, Landbank or through Pesonet).
For January 1 starters, deadline of submission of application is on Aug 31, 2023 (for fellows) and
Sept 15, 2023 (for residents).
For Mid-year starters (fellows), deadline of submission of application is on Feb 29, 2024.
For further inquiries, you may call the Office of the Deputy Director for Health Operations at telephone numbers
8523-4246 or 8554-8400 local 2008
07 Aug 2023
/bles_mdps
