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INTERNS- CLERKS 2021 REVIEW

ONLINE REGISTRATION FORM
To register KINDLY SEND THIS FILE TO: internsclerksreview2021@gmail.com
SEE INSTRUCTIONS ON NEXT PAGE

Name (Last Name, First Name, MI):

Age:
Sex:
Address:
Birthday:
Birthplace:
Mobile No:
Email:
Medical School:
Hospital of Internship (if applicable):
Contact Person and No in case of Emergency:

SUBJECTS/PROGRAM TO BE ENROLLED:

TERMS AND CONDITIONS:

1. The ONLINE review program shall be delivered in accordance with the scope set during orientation
and/or as announced prior.
2. The center reserves the right to modify program details as to schedule, facilities, lecturers etc,
whenever needed, with the objective of better service to the students.
3. The center reserves the right to use the name and/or photo of the undersigned for marketing purposes
in case he/she passes and/or tops the licensure exam.
4. ALL parts of ANY review material (hardcopy and digital copy) are protected with a copyright. Any form
of reproduction without permission will be subjected to legal action.
5. Enrolment to the center is voluntary and from your free will, and was not imposed by any external body.
6. The center does not give refund on down payment, and full payment is required once review has
started.
7. During health crisis, the center will observe all precautionary measures and maintain a “Health and
Safety First” conduct.
8. The center is not responsible for any loss of personal belongings, accidents, health-related problems
on the whole duration of the program as safety precautions must be observed at all times by individuals.

I hereby certify that the above-mentioned information is true and correct. Moreover, I hereby agree to the
above-mentioned terms and conditions, and subject myself to the rights, privileges, benefits, and
responsibilities inherent upon these terms.

________________________
Sign above Printed Name
In case you cannot affix an electronic signature, IN ADDITION TO SENDING THIS ONLINE
FORM, kindly PRINT this form, accomplish it completely, and MANUALLY sign your name. THEN
TAKE A PHOTO OF THE FORM then SEND THE FILE to us (either JPEG or PDF format)

Again, if you have an electronic Signature- just send this online form
If no electronic signature- send this online form AND send the printed (with sign) file (JPEG or PDF)

INSTRUCTIONS:
1. Completely fill out this file.
2. Send this file to internsclerksreview2021@gmail.com

3. WE ONLY HAVE VERY LIMITED SLOTS, so to reserve a slot kindly

settle your payment directly to our company treasurer.

Payment details (direct to Company Treasurer):

BDO Account (Checking) if online please click UNIBANK
EXPERTMD REVIEW SPECIALISTS REVIEW CENTER
012838001052

Or At

Payment details if via GCASH

BDO Account
Christopher Rey L. Dacanay
012830008762

4. Send a proof of payment with YOUR NAME at

internsclerksreview2021@gmail.com
5. See you soon Doc!