PAFP Form No.
M-01 PHILIPPINE ACADEMY OF FAMILY PHYSICIANS
Version 3 – 02/2024 #2244 Taft Avenue, Malate, Manila
Tel. 516-2900; Tel./Fax No. 254-
5646
2X2 PICTURE
APPLICATION FOR ASSOCIATE MEMBERSHIP
✘Thru: Residency Thru: Engage in Family Medicine Practice for more than 5 years
PLEASE PRINT:
AGULAY FRANCES BAIÑO _
FAMILY NAME GIVEN NAME MIDDLE NAME
ADDRESS: Residence: BULAO APARTELLE UNIT 405, BRGY. CALLAGUIP, CITY OF BATAC, ILOCOS NORTE 2906
Office: BRGY. CALLAGUIP, CITY OF BATAC, ILOCOS NORTE 2906 _
Preferred Mailing Address ✘ Residence Office/Clinic
Mobile No/Phone No. 09982754670 E-mail Address:
[email protected] _
Age: 26 Date of Birth: 04/21/1998 Place of Birth: CAGAYAN DE ORO CITY
Civil Status: SINGLE Name of Spouse (If Applicable): N/A
Names of Children (If Applicable): N/A
Names of Beneficiaries: Relationship: GAY JACOBE B. AGULAY – MOTHER
NORIEL L. AGULAY - FATHER
School Graduated: MARIANO MARCOS STATE UNIVERSITY – COLLEGE OF MEDICINE Year: 2022
Internship MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER Year: 2022 – 2023
Year Passed Medical Board Exam 2023 P.R.C. #: 0166603
Residency (Name of Dept./Hospital) MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER Date Started: APRIL 1, 2024
Present & Past Positions, Employer & inclusive dates (use another sheet if necessary)
Employer Position Year
N/A
PMA No. 2023 Component Society: ILOCOS NORTE MEDICAL SOCIETY
PAFP Chapter: ILOCOS NORTE
Membership in Civic/Social Organizations, Positions (use another sheet if necessary)
N/A
Nature of Practice: Private ✘ Government
Place of Practice/Hospital/Affiliation MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER
N/A
Other Special Interests:
I Certify that the above information are true and correct:
N/A
Applicant’s Signature over Printed Name
ENDORSEMENTS
Thru: Residency Thru: Family Medicine Practice more than 5 years
(Department Head) Local Health Official
Chapter President
(Name of Chapter)
COMMITTEE ON MEMBERS WELFARE AND DEVELOPMENT
Application Received by: Date Received
Credentials Evaluated by:
Committee Member/En Banc
( ) Approved ( ) Disapproved ( ) Pending
Chairman, Committee on Credentials
BOARD OF TRUSTEES ACTION:
( ) Approved ( ) Disapproved ( ) Pending
Chair, Standing Committee on Members Welfare and Development
Executive Secretary
Thru: Residency
REQUIRMENTS FOR APPLICATION
1. Completed Information Sheet
2. 2 copies of 2x2 colored picture
3. Valid PIC issued by PRC
4. Valid PMA Card or Certificate of Good Standing
5. Application Fee of P100
6. Upon Approval of membership application, payment of membership Dues
Thru: Engage in Family Medicine Practice for more than 5 years
1. Completed Information Sheet
2. 2 copies of 2x2 colored picture
3. Valid PIC issued by PRC
4. Valid PMA Card or Certificate of Good Standing
5. Application Fee of P100
6. Patient Registry and Census
7. Picture of the Clinic/Facility
8. Picture of Activities (Patient care and Community involvement)
9. Upon Approval of membership application, payment of membership Dues
