Ateneo de Manila University School of Medicine and Public
HealthFinancial Aid Application Form Financial Aid Application Form
SY 2015 - 2016THIS FORM IS ONLY FOR NEW APPLICANTS
ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN
EXCLUSIVELY FOR FINANCIAL NEED FOR ONLY ONE YEAR, RENEWABLE
ANNUALLY. ANY FINANCIAL AID GRANT =TUITION & FEES COST FAMILY
CONTRIBUTION.
ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE BURDEN AS
POSSIBLE.Instructions
Page 2 of 37
1. This application should be filled out by the APPLICANT &
his/her PARENTS together. ALL QUESTIONS must be answered carefully
and completely. If you do not completely fill this application out,
it will not be processed.2. Submit the following NOW:This fa
application form incLuding:a. Your completed detailed personal
NEEDS ESSAY by the applicant at the bottom of this form explaining
WHY YOU NEED financial aid. Do NOT use your ADMISSION ESSAY or
SIMPLY ASK FOR FINANCIAL AID. You must explain WHY YOU NEED HELP so
include details of the FAMILYS FINANCIAL SITUATION as part of the
explanation. This ESSAY MUST BE COMPLETE AND TRUTHFUL. b. PHOTOS
(either HARD COPIES or SOFT COPY pasted below) of personal or
family assets. These must be LABELED and attached at the end of
this applicationi. PERMANENT and LOCAL HOUSES/APARTMENTS/ CONDOS/
FARMS / etc (whether owned, borrowed, loaned, or rented) where you
stay showing the OUTSIDE (FRONT, BACK, SIDES) of the HOUSE or
apartment as well as the ROOMS INSIDE.ii. EACH VEHICLE (whether
owned, borrowed, loaned, or rented) showing the FRONT and SIDE of
EACH VEHICLEiii. EACH PROPERTY, LOT, or HOUSE (other than PERMANENT
or LOCAL RESIDENCES) (whether owned, borrowed, loaned, or rented)
SHOWING the OUTSIDE (front, back, sides) of the HOUSE or PROPERTY
as well as the ROOMS inside the house.3. To be submitted BEFORE or
AT THE INTERVIEW:a. Certificate of Employment & Compensation
for currently employed parents, sibilings or applicants (including
bonuses, commissions, and 13th month pay allowances) for the
current year from current employer/company for each employed parent
and sibling of the applicant still residing with the family;b. If
parents are self-employed, please submit a detailed description of
the business and an income & expense financial statement for
the year;c. If parents were retired or RETRENCHED IN the past three
years, please submit a copy of certification indicating amount of
retirement or separation benefits, if received.d. Latest income tax
return for each employed/self-employed parent of applicant. If not
available, please explain in your PERSONAL ESSAY;4. All information
will be kept STRICTLY confidential.5. Place your documents in a
SEALED LEGAL SIZE BROWN ENVELOPE LABELED with YOUR NAME (LAST,
FIRST, MI) IN THE UPPER LEFT CORNER
Submit these documents to: ASMPH Financial Aid Committee
Registrars Office, ASMPH, Ortigas Ave. 1604, Pasig City
DOCUMENTS CHECKLIST: THIS Financial Aid Application WITH
Personal Needs Essay written by the Applicant AND Photos of:
Residences, houses, dorm rooms, lots, etc Vehicles Last name,
first, MI TO: ASMPH Financial Aid Committee Registrars Office,
ASMPH , Ortigas Ave. 1604, Pasig CityParents and/or Applicants
Certificate of employment OR Parents and/or Applicants
Self-employed Business description & balance sheets or
Retirement or retrenchment information BIR I.T.R. FOR 2014 Legal
size brown envelope Applicants Name in TOP LEFT corner as Last
name, first name, MI
Ateneo de Manila University School of Medicine and Public
Health
Financial Aid Application Form SY 2015 - 2016
THIS FORM IS ONLY FOR NEW APPLICANTS PLEASE TYPE / COPYPASTE,
PRINT & SUBMIT IN HARD COPY Do Not EMAIL
Please PASTE a SOFT or HARD copy of Recent 2 x 2 Photo of The
Applicant(IF HARD COPY, PLEASE WRITE YOUR NAME AT THE BACK)ASMPH
FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN
EXCLUSIVELY FOR FINANCIAL NEED FOR ONLY ONE YEAR, RENEWABLE
ANNUALLY. ANY FINANCIAL AID GRANT = TUITION & FEES COST FAMILY
CONTRIBUTION. ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE
BURDEN AS POSSIBLE.
Please PRINT or TYPE. Credentials filed in support of this
application become the property of the Ateneo de Manila University
and are NOT returnable to the applicant. Misrepresentation of
Information requested in this application will be considered
sufficient reason for refusal of admission and exclusion.
LEGAL NAME
________________________________________________________________________________(Name
in Birth Certificate) Last NameFirst NameMiddle Name
Nickname ____________________ School
________________________________________________________
Degree
_______________________________________________________Date of
graduation ______________
Cumulative QPI/GPAwhere highest grade is equivalent to 4 5 1
NMAT%taken when Part I%Part I%
VerbalInductive ReasoningQuantitativePerceptual Acuity
BiologyPhysicsSocial ScienceChemistry
Are you graduating with HONORS?[ ] No [ ] Yes, I
graduated/expect to graduate: [ ] Summa Cum Laude [ ] Magna Cum
Laude [ ] Cum Laude [ ] Honorable Mention
1. SCHOLARSHIP REQUEST PERCENTAGE GRANT REQUESTED 100% TF 90% TF
80% TF 70% TF 60% TF 50% TF 40% TF 30% TF 20% TF 10% TF
If you are NOT granted financial aid, will you continue in
ASMPH? [ ] Yes [ ] No
If you received financial aid in COLLEGE, how much did you
receive? (check all that apply) 100TF 75TF 50TF 25TF _____Dorm
Books Food _________
2. PERSONAL INFORMATIONPermanent Address
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
Mailing Address(If not the same as permanent add.)
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
LOCAL Address where you stay during school
Street No. Street Subdivision/Barangay City/Municipality ZIP
code
You live with/in[ ] relatives [ ] a boarding house/dorm [ ]
house/condo/apartment [ ] other ___________________ How many do you
share with? ________
Applicants phone NumbersResidence( )Area CodeOffice( )Area
Code
Mobile No. 1( )Area CodeMobile No. 2( )Area Code
E-mail Address(s)1.
________________________________________________2.
________________________________________________Gender[ ] Male [ ]
Female
Date of Birth(MM/DD/YEAR)AgePlace of Birth
Citizenship[ ] Filipino [ ] Others, pls. specify PhilHealth[ ]
Yes [ ] No
Civil Status[ ] Single [ ] Married [ ] Separated [ ] Widowed
Blood Type
If married, name of spouse Last Name First Name Middle
NameAge
Contact No.
Mobile No.( )Area CodeAddress if different
3. FAMILY INFORMATIONFATHERPlease indicate if:[ ] Single Parent
[ ] Widowed [ ] Separated [ ] DECEASED
23Is he the Primary Wage earner of Family[ ] Yes [ ] No24Age
Fathers NameLast Name First Name Middle Name
Fathers AddressStreet No. Street Subdivision/Barangay
City/Municipality
Province Country ZIP code
Fathers TelephoneNumbersResidence( )Area CodeOffice( )Area
Code
Mobile No. 1( )Area CodeMobile No. 2( )Area Code
Fathers e-mail Address(s)1. ____________________________________
2. ____________________________________
Fathers educationHighest educational attainment
______________________________________________School/course/years
attended or graduated ____________________________________Year
Graduated __________ Degree
_________________________________________PRC Board exam in
__________________ taken when ________ Passed [ ] yes [ ] no
Fathers employment / earning capacityIf employed, name of
company/employer ______________________________________Location of
employer_______________________________________________________Position
in firm ________________________________ Years in firm
______________[ ] Regular or [ ] Contractual Annual gross salary in
the firm ___________________If self-employed, nature of work
______________________________________________Do you [ ] own or [ ]
share ownership of this business?
If Father is primary wage earner AND currently UNEMPLOYED,
please attach a separate letter explaining when last employed and
reason for unemployment
MOTHERPlease indicate if:[ ] Single Parent [ ] Widowed [ ]
Separated [ ] DECEASED
Is she the Primary Wage earner of Family[ ] Yes [ ] NoAge
Mothers NameLast Name First Name Middle Name
Mothers AddressStreet No. Street subdivision/Barangay
City/Municipality
Province Country ZIP code
Mothers TelephoneNumbersResidence( )Area CodeOffice( )Area
Code
Mobile No. 1( )Area CodeMobile No. 2( )Area Code
Mothers e-mail Address(s)1. ____________________________________
2. ____________________________________
Mothers educationHighest educational attainment
______________________________________________School/course/years
attended or graduated ____________________________________Year
Graduated __________ Degree
_________________________________________PRC Board exam in
__________________ taken when ________ Passed [ ] yes [ ] no
Mothers employment / earning capacityIf employed, name of
company/employer ______________________________________Location of
employer_______________________________________________________Position
in firm ________________________________ Years in firm
______________[ ] Regular or [ ] Contractual Annual gross salary in
the firm ___________________If self-employed, nature of work
______________________________________________Do you [ ] own or [ ]
share ownership of this business?
If Mother is primary wage earner AND currently UNEMPLOYED,
please attach a separate letter explaining when last employed and
reason for unemployment
GUARDIAN (If applicable)Relationship to you:
Is he/she responsible for your financial needs :[ ] Yes [ ]
NoAge
Guardians NameLast Name First Name Middle Name
Guardians AddressStreet No. Street Subdivision/Barangay
City/Municipality
Province Country ZIP code
Guardians TelephoneNumbersResidence( )Area CodeOffice( )Area
Code
Mobile No. 1( )Area CodeMobile No. 2( )Area Code
Guardians e-mail Address(s)1.
____________________________________ 2.
____________________________________
Guardians educationHighest educational attainment
______________________________________________School/course/years
attended or graduated ____________________________________Year
Graduated __________ Degree
_________________________________________PRC Board exam in
__________________ taken when ________ Passed [ ] yes [ ] no
Guardians employment / earning capacityIf employed, name of
company/employer ______________________________________Location of
employer_______________________________________________________Position
in firm ________________________________ Years in firm
______________[ ] Regular or [ ] Contractual Annual gross salary in
the firm ___________________If self-employed, nature of work
______________________________________________Do you [ ] own or [ ]
share ownership of this business?
If Guardian is primary wage earner AND currently UNEMPLOYED,
please attach a separate letter explaining when last employed and
reason for unemployment
Person to Contact in case of emergency[ ] Father [ ] Mother [ ]
Guardian [ ] Spouse [ ] Other (please specify name)
________________________________________
Emergency Contact AddressStreet No. Street Subdivision/Barangay
City/Municipality
Province Country ZIP code
Emergency Contact Telephone NumbersResidence( )Area CodeOffice(
)Area Code
Mobile No. 1( )Area CodeMobile No. 2( )Area Code
SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a
separate sheet if needed
NAMEAgeSchool last attendedYear Level CourseGraduated
Attach a separate sheet if needed
4. APPLICANT ACADEMIC INFORMATIONSCHOOLS ATTENDED (List all
schools attended beginning from lowest grade)
Elementary School
Levels AttendedGr. _____ To ______
AddressPeriod Covered19 _____ to 20 ______
High School
Levels AttendedYr. _____ To ______
AddressPeriod Covered20 _____ to 20 ______
College
Degree
AddressPeriod Covered20 _____ to 20 ______
Post Graduate(Including other College of Medicine)Degree
AddressPeriod Covered20 _____ to 20 ______
List any honors or prizes you have received for academic
excellence in HS / College or at special events such as science
contests, writing contests, etc. (indicate honors and year, ex. 2nd
Honors, Freshman; Honorable Mention, Sophomore; Prize won,
sponsoring group, year). You may use a separate sheet in needed.
Attach a separate sheet if needed
Attach a separate sheet if needed
5. EXTRA-CURRICULAR ACTIVITIESList your college extra-curricular
activities, including positions held or special responsibilities
and year. (e. Dramatics 1,2,3,4; Class Secretary 2,4; Basketball
Varsity 1,3) Attach a separate sheet if needed
List your community and / or church activities. Attach a
separate sheet if needed
Other work experience after graduation from College - Attach a
separate sheet if needed
PositionCompany and AddressDate
Were you ever dismissed, suspended or placed on probation? [ ]
Yes [ ] No If Yes, specify dates, offenses, penalties
______________________________________________Please attach a
separate sheet explaining the circumstances
6. Total FAMILY INCOME Per YearIf A PARENT or SIBLING SENDS
MONEY from outside the Philippines,PLEASE LIST ONLY THE MONEY THEY
SEND
6A. FAMILY INCOME
If PARENT OR SIBLING SENDS MONEY from OVERSEAS, below LIST ONLY
THE MONEY SENT2014 2014 INCOME ACTUALLY RECEIVED2014 INCOME UNPAID
or OWEDPROJECTED INCOME for 2015
Father
Mother
Brothers
Sisters
6A. FAMILY INCOME SUB-TOTAL
6B. Support from RELATIVES & FRIENDS For the following, ALSO
fill out Section 272014 2014 INCOME ACTUALLY RECEIVEDINCOME UNPAID
or OWEDPROJECTED INCOME for 2015
Grandparents
Uncles
Aunts
Other relatives
Friends
Other
Other
6B. RELATIVES & FRIENDS SUB-TOTAL
Attach a separate sheet if needed
6C. PROFITS EARNED IN RP2014 INCOME ACTUALLY RECEIVEDINCOME
UNPAID or OWEDPROJECTED INCOME for 2015
Profit on Business
Profit/Rentals on Lands
Rentals on Residence/Buildings
Commissions
Retirement Benefits/Pension
OTHER
OTHER
6C. PROFITS EARNED Sub-total
Attach a separate sheet if needed
6D. INTEREST INCOME FROM INVESTMENTS
Interest on Savings accounts
Interest on Time Deposit
Interest on Money Market Placements
Interest on Market Value of Securities
Interest on Stocks
Interest on Foreign Currency Deposit
Interest on Other Investments:
OTHER
OTHER
6D. INTEREST Income Sub-total
Attach a separate sheet if needed
6E. Other LOCAL Income (specify): 2014 INCOME ACTUALLY
RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015
__________________________________
__________________________________
6E. OTHER INCOME Sub-total
Attach a separate sheet if needed
7. REQUIRED Additional INFORMATION ABOUT Annual PAID Income of
APPLICANT SCHOLAR
THIS INCLUDES SUPPORT RECEIVED BY THE APPLICANT from PART/FULL
TIME WORK, or from RELATIVES, FRIENDS, DONORS, other SCHOLARSHIPS
or other NON FAMILY SOURCES
Name of employer, relative, friends, scholarship or donor who
helps you2014 INCOME ACTUALLY RECEIVEDUNPAID or OWEDPROJECTED
INCOME for 2015
7. Total APPLICANT INCOME for 2014
Attach a separate sheet if needed
8. REQUIRED INFORMATION on BORROWING FOR LIVING
This includes money borrowed FOR LIVING EXPENSES from family,
friends, banks, credit cards, credit unions, SSS, GSIS, PagIbig,
etc.
LENDERTotal 2014 Amount BorrowedTotal still UNPAID or
OWEDPROJECTED LOANS for 2015
Borrowed from FAMILY
Borrowed from FRIENDS
Borrowed from SSS
Borrowed from GSIS
Borrowed by Salary loan
Other (specify): __________________________
Borrowed from BANKS (specify each)
Bank 1 ___________________________________
Bank 2 ___________________________________
Bank 3 ___________________________________
Borrowed using CREDIT CARDS (specify each)
Card 1 ___________________________________
Card 2 ___________________________________
Card 3 ___________________________________
8. Total LOANS FOR LIVING for 2014
Attach a separate sheet if needed
9. Total Gross Annual Income SUMMARY
PLEASE COPY THE TOTALS FROM ABOVE 2014 INCOME ACTUALLY
RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015
6A. FAMILY INCOME (page 8)
6B. RELATIVES & FRIENDS (page 8)
6C. PROFITS EARNED (page 9)
6D. INTEREST Income (page 9)
6E. OTHER INCOME (page 9)
7. Total APPLICANT INCOME (page 10)
8. Total LOANS FOR LIVING (page 10)
Total Gross Annual Income =
10. REQUIRED Additional INFORMATION ABOUT GROSS INCOME OF FAMILY
MEMBERS SENDING FROM ABROAD
If PARENT OR SIBLING SENDS MONEY from OVERSEAS, LIST THEIR GROSS
INCOME below:
2014 GROSS FOREIGN INCOMEUNPAID or OWEDPROJECTED INCOME for rest
of 2015
Father
Mother
Brothers
Sisters
Other
Other
Attach a separate sheet if needed
11. Total MONTHLY FAMILY Expenses (In Philippines only)
If the applicant DOES NOT LIVE WITH THE FAMILY DURING SCHOOL
YEAR,DO NOT ADD APPLICANT DORM EXPENSES TO FAMILY EXPENSES
BELOWInstead, please ANSWER DORM SECTION below.
11A. BASIC MONTHLY FAMILY EXPENSES2014 EXPENSES ACTUALLY
PAID2014 EXPENSES UNPAID or OWEDPROJECTED COSTS for 2015
Food
Grocery
House Rent
Electricity
Water
LPG
Telephone (landline)
DSL/ Broadband
Cable TV
Cell phone Load (Do NOT include Applicant)
Non-school Clothing (Do NOT include Applicant)
School Uniforms/clothing (Do NOT include Applicant)
Transportation (PARENTS)
Transportation (SIBLINGS ONLY)
School Bus or car pool (SIBLINGS ONLY)
Salaries of helper, housekeeper, driver, etc. working only for
family
(if total FOR MEDICINES or MEDICAL TREATMENTS is P500 per month
or GREATERYOU MUST fill out Section 25 BELOW
MEDICINES
MEDICAL TREATMENTS
MONTHLY EXPENSES FOR APPLICANT LIVING WITH FAMILY (IF APPLICANT
LIVES IN A DORM NOW THEN SKIP THIS SECTION AND ANSWER IN DORM
SECTION BELOW)
Cell phone load
Non school Clothing
School Uniforms/clothing
Food purchased in school BY APPLICANT
Transportation costs to & from school BY APPLICANT
Xeroxing, etc. BY APPLICANT
______________________________________
11A. Sub-total for BASIC MONTHLY FAMILY EXPENSES
Attach a separate sheet if needed
11B. MONTHLY LOAN PAYMENTS (banks, SSS, PagIbig, family, friends
etc)
(please identify to whom/why paid and if loan is for
business)2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for
2015
Mortgage Amortization
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11B. Sub-total for MONTHLY loan payments
Attach a separate sheet if needed
11C. AVERAGE MONTHLY CREDIT CARD PAYMENTS
URGENT: IF YOU HAVE CREDIT CARD LOANS, YOU MUST ANSWER SECTION 8
above
IMPORTANT: BEFORE LISTING BELOW DEDUCT MONTHLY EXPENSES (like
food/ groceries/ electricity/etc.) which were paid by CREDIT CARD
and LISTED ABOVE
(please identify CARD)AVERAGE MONTHLY PAIDAVERAGE MONTHLY UNPAID
BALANCEPROJECTED MONTHLY COSTS for 2015
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11C.Sub-total for MONTHLY credit card payments
Attach a separate sheet if needed
11D. Other Monthly Payments (please identify to whom/why
paid)2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for
2015
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11D. Sub-total other monthly payments
Attach a separate sheet if needed
11ABCD. TOTAL BASIC FAMILY EXPENSES per MONTH
(11A+11B+11C+11D)
11E. DORM SECTION: If YOU DO NOT LIVE WITH YOUR FAMILY (i.e.
Dorm, shared apartment, room or coop, etc.), ANSWER BELOW:
ADDRESS WHERE YOU STAYED WHILE IN SCHOOLHOW MANY DO YOU SHARE
WITH?
IF YOU ARE MOVING CLOSER TO ASMPH, WHERE WILL YOU STAY NEXT? HOW
MANY OTHERS WILL YOU SHARE WITH?
AVERAGE MONTHLY ACTUALLY PAIDAVERAGE MONTHLY UNPAID or
OWEDPROJECTED COSTS for 2015
Share of Rent per month paid by applicant
Share of condo dues paid by applicant
Share of Electricity/water/gas
Food purchased while in school or hospital
Food purchased/delivered to dorm/condo
Transportation costs to/from dorm/condo/etc
Transportation costs to/from parents
Xeroxing, etc.
Internet in dorm or broadband
Books
____________________________________________
____________________________________________
11E. Sub-total for DORMEXPENSES
Attach a separate sheet if needed
11. TOTAL MONTHLY FAMILY EXPENSES (11A+11B+11C+11D+ 11E) (Basic
+ Dorm)
TOTAL of MONTHLY FAMILY EXPENSES for 1 year
MONTHLY X 12 MONTHS =
12. Total ANNUAL FAMILY Expenses (In Philippines only)
12A. TUITION PAID 2014Please list names of who is receiving
tuition help2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS
for 2015
1 APPLICANT
2
3
4
5
6
7
8
Attach a separate sheet if needed
12B. ANNUAL NON-TUITION EXPENSES2014 ACTUALLY PAID2014 UNPAID or
OWEDPROJECTED COSTS for 2015
Withholding Tax (per year)
Insurance Plans (compute per year)
SSS/GSIS/Pag-Ibig
PhilHealth (PARENTS & SIBLINGS)
PhilHealth (APPLICANT)
HOSPITALIZATIONS or MEDICAL CARE (Please answer SECTION 25
below)
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
12. Sub-total for ANNUAL family EXPENSES (12A+12B)
Total ANNUAL Expenses
(monthly x 12) + (Annual) =
Summary of Total FAMILY LOAN / CREDIT Expenses
2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for
2015
YEARLY LOAN EXPENSES
YEARLY CREDIT CARD EXPENSES
TOTAL DEBT
13. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET
Please copy your totals and enter them below:2014 ACTUALLY
PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015
Total Gross Annual Income from page 11 above+++
Total Annual Expenses from bottom of page 15 above------
Surplus/ Loss for the year
NOTE
IF FAMILY Loss for the year is SIGNIFICANTLY NEGATIVE(i.e. your
family SPENDS more than 10% than it EARNS)YOUR PARENTS ARE REQUIRED
TO attach a special letter EXPLAINING how they ARE ABLE TO PAY
THIS.DO NOT SKIP THIS STEP
14. PERSONAL POSSESSIONS DECLARATION
Please list all possessions worth more than P1, 000 that you
PERSONALLY use regularly even if you do not own them. Be VERY
complete & clear - these details are subject to verification
Leave any item blank if not applicable
ItemName/brand/model #If this is NOT exclusively for you, who
else uses itAcquired WhenApproximateAcquisition Cost
Laptop
PC / Tablet
Printer
External Hard Drive
Cellular phone1
Cellular phone2
Cellular phone3
DSL line
Wi-Fi account
Digital recorder
Broadband account
Tape recorder
TV set(s)
VHS/VCD/DVD
Refrigerators/Freezers
Microwave/Oven
Washing Machine/Dryer
Air conditioner
Piano/organ
Braces
Car (fill out section 19)
Jewelry/watch (specify):
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
15. FAMILY HOUSEHOLD POSSESSIONS DECLARATIONPlease list all
FAMILY possessions worth more than P2,500 that your FAMILY uses
regularly even if your family does not own them. Be VERY complete
& clear - these details are subject to verification Leave any
item blank if not applicable
Brand(s) & Model(s)Acquired WhenCost
TV sets
VHS/VCD/DVD
Stereo/Karaoke
Cellular phones
Laptop
PC
Printer
Refrigerators/ Freezers
Microwave/Oven
Washing Machine/Dryer
Air conditioner
Piano/organ
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
16. Personal & Family MembershipsPlease list all memberships
costing worth more than P1,000 per month that you or your FAMILY
have or use even if not paid for by you or your family. Memberships
can be in gym, golf club, sports club, etc. Be VERY complete &
clear - these details are subject to verification.
MembershipFor what purposeAcquired WhenCost
Attach a separate sheet if needed17. Personal BANK
ACCOUNTSPlease list ALL YOUR BANK ACCOUNTS that you USE whether
they are yours or not.Be VERY complete & clear - these details
may be subject to verification.
BankType of account (savings/checking/atm)Acquired WhenCurrent
balance
Attach a separate sheet if needed18. Family BANK ACCOUNTSPlease
list ALL YOUR FAMILYS BANK ACCOUNTS that they OWN or USE Be VERY
complete & clear - these details may be subject to
verification.
Bank Type of account (savings/checking/atm)Who uses the
cardAcquired WhenCurrent balance
Attach a separate sheet if needed
19. Personal Credit or Debit CardsPlease list ALL CREDIT or
DEBIT CARDS that you USE whether you pay for it or not. Be VERY
complete & clear - these details are subject to
verification.
Credit or Debit CardWho Pays the BillAcquired WhenCurrent Credit
Limit
Attach a separate sheet if needed20. Family Credit or Debit
CardsPlease list ALL CREDIT or DEBIT CARDS that your FAMILY USES
whether they pay for it or not.Be VERY complete & clear - these
details are subject to verification.
Credit or Debit CardWho uses the cardWho Pays the BillAcquired
WhenCurrent Credit Limit
Attach a separate sheet if needed21. Domestic OR International
Travel By YOU Personally OR by Your IMMEDIATE FAMILY during the
past 3 YEARSThis includes all INTERNATIONAL trips and ANY LOCAL
TRAVEL BY PLANE or MORE THAN 5 HOURS by CAR, BUS, etc. Leave blank
if not applicable.Be VERY complete & clear - details are
subject to verification
Person(s) traveling & relationship to you:Purpose (vacation,
emergency, etc.)Dates of tripDestination(s)By Ship Airline, Bus, or
Car EstimatedCost of tripWho paid for the trip?
Attach a separate sheet if needed22. Personal & Family
Vehicle DeclarationPlease list all vehicles that YOU or your FAMILY
uses regularly even if your family does not own them. Be VERY
complete & clear - these details are subject to
verification
PLEASE ATTACH RECENT PHOTOGRAPHS OF EACH VEHICLE SHOWINGTHE
FRONT and SIDE of EACH VEHICLE
Make/Yr ModelWhen PurchasedAmt of PurchaseAmt Paid
ForCompany/Family Owned
Attach a separate sheet if needed23. Family Properties Owned OR
USED (residential, commercial, etc.)PLEASE ATTACH RECENT
PHOTOGRAPHS of EACH PROPERTY or HOUSE SHOWING the OUTSIDE (FRONT,
BACK, SIDES) of the HOUSE or PROPERTY as well as the ROOMS INSIDE
THE HOUSE.
Description and/or useLocationSizeAcquired WhenValue at
AcquisitionPresent Market ValueYearly Net Income
Attach a separate sheet if needed24. Siblings No Longer In
SchoolNameAgeCivil StatusStill residing with you?Highest
educational attainment & school attendedWhere employed (Company
& Location)*Position in the Firm**Annual Gross Income**
Attach a separate sheet if needed *If unemployed, state
reason.**Do not leave blank.25. Serious Acute OR Chronic
IllnessesIf your monthly medical or medicine bills are P500 or
greater per month, please detail the serious medical, surgical,
physical or mental disabilities, or mental illnesses which cause
your family to spend.
NameAgeRelation to youDiagnosis# of times
hospitalizedCurrenttreatment /medicines requiredEst. annual
treatment cost
Attach a separate sheet with Summary History of Present Illness
for each patient
Attach a separate sheet if needed26. Other Dependents Living In
Your House
NameAgeCivil StatusRelation to youReason for staying with
familyWhere employed (Company & Location)*Position in the
Firm**Annual Gross Income**
Attach a separate sheet if needed *If unemployed, state
reason.**Do not leave blank.27. Relatives, Friends, Etc. Who Help
With Household & Educational Expenses
Indicate duration and extent of financial support (for whom, how
much per month/year).
NameRelation to youWho receives helpHelp for whatWhen did they
start helpingHow much per monthTotal per yearIf they will not
continue, why
Attach a separate sheet if needed28. Scholarships &
Educational PlansAre any of your siblings presently or PREVIOUSLY
on scholarship in any school :Yes No
SiblingSchoolMerit/ Athletic/ Financial aidHow much is
granted?
Are YOU or any of your siblings enrolled under an education plan
in any school :Yes No
SiblingSchoolCompanyHow much?
Attach a separate sheet if needed29. Emigration & OFW
DeclarationAre any of your immediate family members under petition
for immigration or have any pending visa application to another
country Yes No
If so, please indicate the names of those who are leaving and
give brief
details.__________________________________________________
__________________________________________________
Does anyone in your immediate family have plans to leave the
country for employment within the next year?Yes No
If so, please indicate the names of those who are leaving and
give brief
details.__________________________________________________
__________________________________________________
30. Working Student DeclarationIf you are a working student, how
many hours do you work:per day? or per week?
What days of the week?
What type of work do you do?
If working interferes with your studying, what do you plan to
do?
31. Your Experience with MedicinePlease answer the following
questions as truthfully as possible:
Are you a member of the pre-med organization? Yes No
Are you a member of any organization which serves poor, sick,
orhospitalized children or adults? Yes No
Have you ever joined a medical mission or helped during any
medical procedures? Yes No
Have you visited any medical schools prior to applying to ASMPH?
Yes No
Have you ever been a patient in a hospital? Yes No
Are any of your relatives actively working as doctors? Yes
No
Have you discussed the life of doctor with a doctor relative or
your doctor or teacher? Yes No
Have you ever spent time with a doctor relative while they
practice medicine? Yes No
Have you ever spent time with a doctor or other health
professional as they do their job? Yes No
Have you ever worked in a hospital or health center as
volunteer? Yes No
On a scale from 1 to 5, please ratehow DO YOU FEEL about the
following:Un-happyVery Confident
12345
Going to school for 10 or more years
Classes are really difficult.
Being dependent on your family for another 5-10 years
Medical lifestyle with hours that are long
Going to class from early morning to early evening
Studying for hours every day of the week
Loss of independence or carefree college lifestyle
5 year mandatory service requirement for ASMPH scholars
ASMPH Scholar requirement to find support for a new ASMPH
scholar within 20 years after ASMPH graduation
Getting through medical school requires giving up many things.
On a scale of 1 to 5, please rate how willing you are to give up
the following:
Won't give up234Willing to give upNA
Your boyfriend/girlfriend?
Your weekends?
Your co-curriculars or orgs or non-worship church
activities?
going to movies
going to gimmicks or parties
reading non medical literature
watching TV or DVDs
Seeing your family as often?
On a scale from 1 to 5, please rate the following:
How much do your parentsWANT you to go to medical school?Against
my going12345TOTALLY determined
How IMPORTANT is it to your parentsthat you become a doctor?Not
important12345Very important
How much did your PARENTS Influence you to become a doctor?No
influence12345Highly influenced
How much did your CLASSMATES or COURSE influence you to become a
doctor?No influence12345Highly influenced
How OFTEN do you have DOUBTSabout going to medical school?No
doubts12345Frequent doubtful
How STRONG is your COMMITMENTto FINISHING medical school?Unsure
if I'll finish)12345Totally committed
How much you REALLYwant to go to medical school?Will go if
accepted12345totally determined
How long have you wanted to become a doctor? Please explain
briefly below:
Do you plan to have a family? Yes No
Do you wish to travel during or after medical school? Yes No
Have you ever thought about starting a business? Yes No
Are you willing to practice in your province after graduation or
residency? Yes No
Where do you plan to work as a doctor after graduation and
why?
Please list all the medical schools have you applied to and rank
them from first choice to last?
If you do not get financial aid, what will you do?
32. OTHER INFORMATIONList any physical problems that should be
taken into consideration in planning your program of studies and
school activities.
Have you ever been forced to stop schooling for a month or more
because of poor health? Give details and dates.
33. Persons to Recommend YouList down two persons in your
community (excluding relatives) or in the Ateneo de Manila
University who know you and your family very well whom the
Committee may get in touch with for possible inquiry. PLEASE DO NOT
LEAVE BLANK. (Do not leave this blank)
Name Address Contact Numbers
_____________________________________________________________________________
_____________________________________________________________________________
34. PERSONAL NEEDS ESSAY (ANSWER BELOW)In order for the
Financial Aid Committee to understand your needs, please write why
you need financial aid. Please describe clearly and simply about
you and your familys needsYou must be honest and complete. Do NOT
write your admission essay or a request for financial aid. Your
MUST explain WHY you and your family NEED FINANCIAL AID. All
information you give is confidential and will not be shared with
anyone without your written permission.(Guidelines: 2-3 pages,
single-spaced, Times New Roman font, and 12 pt.)
Type your ESSAY here:
35. SOFT OR HARD COPIES OF PICTURES OF CARS, HOMES, DORM, ETC
(label each clearly)
Paste soft copies of picture herePaste soft copies of picture
here
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here
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here
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here
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Ateneo de Manila UniversitySchool of Medicine and Public
HealthFinancial Aid Application Form
I/we hereby certify that all information written in this
application is complete and accurate and we are hereby authorized
to verify the same. I/we understand that during the period of any
scholarship granted: misrepresentation of information or
withholding of information requested for my application will be
considered reason for disapproval or cancellation of financial aid
and, where appropriate, grounds for legal action, as well as
referral to the Dean for charges of Academic Dishonesty with the
potential of Dishonorable Dismissal with mandatory repayment of all
grants paid, with interest.
I agree if accepted as a scholar that my admission,
matriculation, and graduation are subject to the rules and
regulations of the Ateneo de Manila University.
________________________________________________________
Applicants Signature Date
________________________________________________________ Parents
or Guardians Signature Date
Ateneo de Manila UniversitySchool of Medicine and Public
Health
APPLICANTS FINANCIAL AUTHORIZATION FORM 2015 2016
APPLICANT NAME
__________________________________________________________________________(Name
in Birth Certificate) Last NameFirst NameMiddle Name
ASMPH Financial Aid APPLICATION NEW 2015-16 Page 4 of 37I,
_____________________________________, hereby certify that all
information written in this application or submitted in support of
this application is complete and accurate.I understand that during
the period of any grant given, misrepresentation of information or
withholding of information requested for my application will be
considered reason for disapproval or cancellation of financial aid
and, where appropriate, grounds for legal action, as well as
referral to the Dean for charges of Academic Dishonesty with the
potential of Dishonorable Dismissal with mandatory repayment of all
grant monies paid.I hereby authorize the Ateneo School of Medicine
and Public Health (ASMPH) to confirm through investigation any
information provided by me for my application for ASMPH financial
aid from whatever sources the school may consider appropriate. I
hereby give permission for physical evaluation that may include,
but is not limited to, unannounced site visits of my family's
permanent residence, real estate, and my dormitory, with physical
inventory of our home and my dorm contents and assets. I also give
specific permission to obtain personal financial information from
the BIR, the LTO, PhilHealth, DOLE, local and international banks,
and any other source of information pertinent to my application for
financial aid. I consent to the use and disclosure by the Ateneo of
information in and relating to my application, to any of its
subsidiaries and affiliates, agents, banks and banking
associations, credit card companies and associations, financial
institutions, credit information bureaus and their equivalent,
third-party service providers rendering services to the Ateneo, as
well as third parties authorized by the ASMPH to receive such
information, wherever situated, for confidential use in connection
with the exercise of its functions to provide financial aid
(including but not limited to credit investigation and collection,
information technology systems and processes, data processing,
imaging and storage, back-up and recovery and risk analyses
purposes). I agree that such disclosure or exchange of information
shall not be the basis of any claim against the School or the
parties to whom the School makes the disclosure. I acknowledge that
the School may disclose any information or data regarding my
application upon orders of courts or requests of competent
government offices or agencies authorized by law. I hereby give
permission for the School to request information and to make
necessary inquiries about me and my family from third parties in
connection with my application for financial aid.I agree if
accepted as a scholar that my admission, matriculation, and
graduation are subject to the rules and regulations of the Ateneo
de Manila University
_________________________________________________________
Applicants Signature over printed name Date
Ateneo de Manila UniversitySchool of Medicine and Public
Health
PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 2015 2016
APPLICANT NAME
__________________________________________________________________________(Name
in Birth Certificate) Last NameFirst NameMiddle Name
ASMPH Financial Aid APPLICATION NEW 2015-16 Page 37 of 37I/WE,
_____________________________________, hereby certify that all
information provided in our application or submitted in support of
this application is complete and accurate. I/WE uring the period of
any grant given understand that misrepresentation of information or
withholding of information requested for this application will be
considered reason for disapproval/cancellation of financial aid
and, where appropriate, grounds for legal action, as well as
referral to the Dean for charges of Academic Dishonesty with the
potential of Dishonorable Dismissal with mandatory repayment of all
grant monies paid.I/WE hereby authorize the Ateneo School of
Medicine and Public Health (ASMPH) to confirm through investigation
any information provided by for our application for ASMPH financial
aid from whatever sources the school may consider appropriate. I/WE
hereby give permission for physical evaluation that may include,
but is not limited to, unannounced site visits of our permanent
residence, real estate, and our childs dormitory, with physical
inventory of our home and dorm contents and assets. I/WE also give
specific permission to obtain personal financial information from
the BIR, the LTO, PhilHealth, DOLE, local and international banks,
and any other source of information pertinent to our application
for financial aid. I/WE consent to the use and disclosure by the
Ateneo of information in and relating to our application, to any of
its subsidiaries and affiliates, agents, banks and banking
associations, credit card companies and associations, financial
institutions, credit information bureaus and their equivalent,
third-party service providers rendering services to the Ateneo, as
well as third parties authorized by the ASMPH to receive such
information, wherever situated, for confidential use in connection
with the exercise of its functions to provide financial aid
(including but not limited to credit investigation and collection,
information technology systems and processes, data processing,
imaging and storage, back-up and recovery and risk analyses
purposes). I/WE agree that such disclosure or exchange of
information shall not be the basis of any claim against the School
or the parties to whom the School makes the disclosure. I/WE
acknowledge that the School may disclose any information or data
regarding our application upon orders of courts or requests of
competent government offices or agencies authorized by law. I/WE
hereby give permission for the School to request information and to
make necessary inquiries about me or my family from third parties
in connection with our application for financial aid.I/WE agree if
accepted as a scholar that our admission, matriculation, and
graduation are subject to the rules and regulations of the Ateneo
de Manila University.
___________________________________________
_____________________________________ Parent/Guardians Signature
over printed name / Date Parents Signature over printed name /
Date