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(Must be SUBMITTED to the Examiner on the day of the test)

Bank Reference Number : 3157566817

NMAT Application Number : 1031507414

Name of Applicant : RICH TAYABAS CONAG

Mailing address : 4 SAWANG ST. CENTRO,
Lal-Lo, Cagayan 3509 Philippines
Name of College Graduating/Graduated From : Medical Colleges of Northern Philippines, Peablanca, Cagayan
Month and Year Graduating/Graduated :
March 2007
Test Center : Manila

Test Date : March 29, 2015


1. For GRADUATING college students, please have your School Head affix his/her signature on the space provided below.
For college GRADUATES, please bring a photocopy of your official Transcript of Records (TOR) and submit it to the Examiner
on the day of the test.
2. Bring this Form to the nearest Bank of the Philippine Islands (BPI) branch and pay the NMAT Registration and Test Fees
(PhP1900.00 PHP) on or before March 06, 2015.
Copy exactly the Bank Reference Number found on the upper left portion of this Form and CEM's BPI account number 18810450-24 on the BPI Payment/Deposit Slip..
3. Check your e-mail (including your spam mailbox) after two (2) banking days for your payment confirmation email. Visit also the
NMAT Online website to verify the status of your NMAT application and to download the NMAT Practice Set and Supplementary
Handout after payment has been confirmed.
4. You must also visit the NMAT Online website two weeks before the test date to know your room assignment and to download your
Examination Permit.
5. Affix your signature on the certification below:

I hereby certify that I have read, fully understand, and accept all the information, terms and conditions specified on the NMAT website,
including the NMAT policies on refund of test fees 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 given on this Form is true and correct to the best of my knowledge and that any misinformation shall constitute grounds for my disqualification from
taking the NMAT or invalidation of my NMAT results.

Signature of the Applicant

Date Signed


Please affix your signature on the space provided below to attest to the identity and academic
status of the person getting your signature.
I hereby certify that the person in the picture is one and the same as the NMAT applicant who is a
candidate for graduation of this institution on the date he/she specified and whose signature
appears above.
Printed Name and Signature of School Head

Designation of School Head

Date Signed


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