Asmph Fa Application - New Student - 2015-16 Final

Ateneo de Manila University
School of Medicine and Public Health
Financial Aid Application Form

Financial Aid Application Form SY 2015 - 2016
THIS 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
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 application
i. PERMANENT and
LOCAL
Page 1 of 45
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.
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;
ii. EACH VEHICLE

(whether owned,
borrowed, loaned, or
rented) showing the
FRONT and SIDE of EACH
VEHICLE
iii. 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
Page 2 of 45
b. If parents are selfemployed, 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/selfemployed 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
Page 3 of 45
DOCUMENTS CHECKLIST:
THIS Financial Aid Application WITH
Personal Needs Essay written by the Applicant AND
Photos of:
Residences, houses, dorm rooms, lots, etc
Vehicles
Parents and/or Applicants Certificate of employment OR Parents and/or

Applicants Self-employed Business description & balance sheets or
Retirement or retrenchment information
Last name, first, MI
BIR I.T.R. FOR 2014

Legal size brown envelope
Applicants Name in TOP LEFT corner as
TO: ASMPH Financial Aid

Committee
Last name, first name, MI

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
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.
Please PASTE a
SOFT or HARD copy
of
Recent 2 x 2
Photo of
The Applicant
(IF HARD COPY,
PLEASE WRITE
YOUR NAME
LEGAL NAME
________________________________________________________________________________
(Name in Birth Certificate)
Middle Name
Last Name
First Name
Nickname ____________________ School

________________________________________________________
ASMPH Financial Aid APPLICATION NEW 2015-16
Page 4 of 45
Degree _______________________________________________________Date of graduation

______________
Cumulative
QPI/GPA
where highest grade is

equivalent to
taken
when
Part I
Verbal
Inductive
Reasonin
g
Quantitativ
e
Biology
Physics
Social
Science
NMAT
4
5
1
Part I
Percept
ual
Acuity
Chemist
ry
[ ] Yes, I graduated/expect to graduate:

Are you graduating [ ] No
[ ] Summa Cum Laude
[]
with HONORS?
Magna Cum Laude
[ ] Cum Laude
Honorable Mention
[]
1. SCHOLARSHIP REQUEST
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 [ ] Yes
No
continue in ASMPH?
50TF 25TF
If you received financial aid in 100TF 75TF
_____
COLLEGE,
how much did you receive? (check all Dorm Books Food
that apply) _________
PERCENTAGE
GRANT
REQUESTED
100% TF
2. PERSONAL INFORMATION
Permanent
Address
Street No.
City/Municipality
Street
Subdivision/Barangay
Province
Country
ZIP code
Mailing
Address
(If not the
same as
permanent
add.)
Street No.
City/Municipality
Province
ZIP code
Street
Country
Page 5 of 45
LOCAL
Address
where you
stay during
school
You live
with/in
Applicant
s phone
Numbers
E-mail
Address(s)
Street No.
City/Municipality
[ ] relatives
[ ] a boarding house/dorm
house/condo/apartment
[ ] other ___________________
________
(
Residence
[]
How many do you share with?
Office
Area Code
Mobile No.
1
Area Code
Mobile No.
2
Area Code
Area Code
1. ________________________________________________
Gend
2. ________________________________________________
er
Date of
Birth
(MM/DD/YEA
R)
Citizenshi [ ] Filipino
p
Civil [ ] Single
Status ] Widowed
If
married,
Last Name
name of
Middle Name
spouse
Contact
No.
Street
ZIP code
pls. specify
[ ] Married
Mobile No.
(
)
Area Code
Female
Place of
Birth
Age
[ ] Others,
[ ] Male
[ ]
[ ] Separated
PhilHealt
h
Blood
Type
[ ] YES [
] NO
Age
First Name
Address
if
differen
t
3. FAMILY INFORMATION
FATHER
23
PLEASE
INDICATE IF:
Is he the Primary Wage earner of

Family
[ ] SINGLE PARENT
SEPARATED
[ ] YES
[ ] WIDOWED
[ ] DECEASED
[ ] NO
24
Fathers
Last Name
Name Middle Name
Street No.
Fathers City/Municipality
Address
Province
[]
Age
First Name
Street
Country
ZIP code
Page 6 of 45
Fathers
Telephone
Numbers
Reside
nce
(
)
Area Code
Office
(
)
Area Code
Mobile
No. 1
(
)
Area Code
Mobile
No. 2
(
)
Area Code
Fathers
e-mail
Address(s)
Fathers
education
1. ____________________________________
____________________________________
2.
Highest educational attainment

______________________________________________
School/course/years attended or graduated
____________________________________
Year Graduated __________
Degree
_________________________________________
PRC Board exam in __________________ taken when ________
[ ] yes [ ] no
Passed
If employed, name of company/employer

______________________________________
Location of
Fathers employer_______________________________________________________
Years in firm
employmen Position in firm ________________________________
t / earning ______________
[ ] Regular or [ ] Contractual
Annual gross salary in the firm
capacity
___________________
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
MOTHE
R
PLEASE
INDICATE IF:
[ ] SINGLE PARENT
SEPARATED
Is she the Primary Wage earner

of Family
Mothers
Name
[ ] YES
[ ] WIDOWED
[ ] DECEASED
[]
Age
[ ] NO
Last Name
Middle Name
First Name
Street No.
Street
Mothers City/Municipality
Address
subdivision/Barangay
Province
Country
ZIP code
Mothers
Telephone
Numbers
Mothers
e-mail
Address(s)
Reside
nce
(
)
Area Code
Office
(
)
Area Code
Mobile
No. 1
(
)
Area Code
Mobile
No. 2
(
)
Area Code
1. ____________________________________
____________________________________
2.
Page 7 of 45
Mothers
education

______________________________________________
____________________________________
Degree
_________________________________________
[ ] yes [ ] no
Passed

______________________________________
Location of
Mothers employer_______________________________________________________
Years in firm
employmen Position in firm ________________________________
______________
t / earning
[ ] Regular or [ ] Contractual
capacity
___________________
______________________________________________
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
Is he/she responsible for your financial

needs :
Guardians
Name
Guardians
TO
YOU:
[ ] YES
Ag
e
[ ] NO
Last Name
Middle Name
First Name
Street No.
City/Municipality
Street
Address
Province
Country
ZIP code
Guardians
Telephone
Numbers
Guardians
e-mail
Address(s)
Guardians
education
Guardians
employment
Residen
ce
Mobile
No. 1
Office
Area Code
Area Code
Area Code
Mobile
No. 2
Area Code
1. ____________________________________
____________________________________
2.

______________________________________________
____________________________________
Degree
_________________________________________
[ ] yes [ ] no
Passed

______________________________________
Page 8 of 45
Location of
employer_______________________________________________________
Position in firm ________________________________
Years in firm
/ earning ______________
capacity [ ] Regular or [ ] Contractual
___________________
______________________________________________
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
Emergency
Contact
Address
Emergency
Contact
Telephone
Numbers
[ ] Father
[ ] Mother
[ ] Guardian
Spouse
[ ] Other (please specify name)
________________________________________
Street No.
City/Municipality
Province
ZIP code
)
Resid (
Area
Code
ence
Mobil
e No.
1
Street
[]
Country
Office
(
)
Area Code
Mobile No. 2
(
)
Area Code
(
)
Area Code
SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a

separate sheet if needed
NAME
Age
School last attended
Year Level
Cours Graduat
e
ed
Attach a separate sheet if needed
4.
APPLICANT ACADEMIC INFORMATION
SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)
Elementary
Levels
Page 9 of 45
School
Attended
Addre
ss
Period
Covered
High School
Levels
Attended
Addre
ss
Period
Covered
College
Gr. _____ To
______
19 _____ to 20
______
Yr. _____ To ______
20 _____ to 20
______
Degree
Addre
ss
Post
Graduate
(Including
other College
of Medicine)
Period
Covered
20 _____ to 20
______
Degree
Addre
ss
Period
Covered
20 _____ 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
EXTRA-CURRICULAR ACTIVITIES
5.
List 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

Position
Company and Address
Date
Were you ever dismissed, suspended or placed on probation?

] Yes
[ ] No
[
Page 10 of 45
If Yes, specify dates, offenses, penalties

______________________________________________
Please attach a separate sheet explaining the circumstances
6.
Total FAMILY INCOME Per Year
If 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 SENT
2014 2014
INCOME
ACTUALLY
RECEIVED
2014
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
2015
2014 2014
INCOME
ACTUALLY
RECEIVED
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
2015
Father
Mother
Brothers
Sisters
6A. FAMILY INCOME
SUBTOTAL
6B. Support from

RELATIVES &
FRIENDS
For the following, ALSO fill out
Section 27
Grandparents
Uncles
Aunts
Other relatives
Friends
Other
Other
6B. RELATIVES & FRIENDS
SUB-TOTAL
Page 11 of 45
6C. PROFITS EARNED

IN RP
2014
INCOME
ACTUALLY
RECEIVED
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
2015
Profit on Business
Profit/Rentals on Lands
Rentals on
Residence/Buildings
Commissions
Retirement Benefits/Pension
OTHER
OTHER
6C. PROFITS EARNED Subtotal
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 Subtotal
6E. Other LOCAL

Income (specify):
2014
INCOME
ACTUALLY
RECEIVED
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
2015
__________________________________
Page 12 of 45
__________________________________
6E. OTHER INCOME Sub-total
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 you
2014 INCOME
ACTUALLY
RECEIVED
UNPAID or
OWED
PROJECTED
INCOME for
2015
7. Total APPLICANT INCOME for

2014
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.
Total 2014
Amount
Borrowed
LENDER
Total still
UNPAID or
OWED
PROJECTE
D 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
___________________________________
Page 13 of 45
Bank 2
___________________________________
Bank 3
___________________________________
Borrowed using CREDIT CARDS (specify each)

Card 1
___________________________________
Card 2
___________________________________
Card 3
___________________________________
8. Total LOANS FOR LIVING for

2014
9. TOTAL
GROSS ANNUAL INCOME SUMMARY

2014
PLEASE COPY THE
INCOME
INCOME
PROJECTE
TOTALS FROM ABOVE ACTUALLY UNPAID D INCOME
RECEIVED
or OWED
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
=
Page 14 of 45
REQUIRED Additional INFORMATION

ABOUT GROSS INCOME OF FAMILY
MEMBERS SENDING FROM ABROAD
10.
If PARENT OR SIBLING SENDS MONEY from OVERSEAS,

LIST THEIR GROSS INCOME below:
2014
GROSS
FOREIGN
INCOME
UNPAID
or OWED
PROJECTE
D INCOME
for rest of
2015
Father
Mother
Brothers
Sisters
Other
Other
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
BELOW
Instead, please ANSWER DORM SECTION below.
11A. BASIC MONTHLY

FAMILY EXPENSES
2014
EXPENSES
ACTUALLY
PAID
2014
EXPENSES
UNPAID or
OWED
PROJECTED
COSTS for
2015
Food
Grocery
House Rent
Electricity
Water
LPG
Telephone (landline)
DSL/ Broadband
Cable TV
Page 15 of 45
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 GREATER
YOU 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
11B. MONTHLY LOAN PAYMENTS
(banks, SSS, PagIbig,
family, friends etc)

(please identify to whom/why
paid and if loan is for business)
2014
ACTUALLY
PAID
2014
UNPAID or
OWED
PROJECTED
COSTS for
2015
Mortgage Amortization
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Page 16 of 45
11B. Sub-total for

MONTHLY loan payments
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
AVERAGE
MONTHLY
PAID
(please identify CARD)
AVERAGE
MONTHLY
UNPAID
BALANCE
PROJECTED
MONTHLY
COSTS for
2015
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11C.Sub-total for
MONTHLY
credit card payments
11D. Other Monthly

Payments (please identify to
whom/why paid)
2014
ACTUALLY
PAID
2014
UNPAID or
OWED
PROJECTED
COSTS for
2015
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11D. Sub-total other monthly

payments
11ABCD. TOTAL BASIC

FAMILY EXPENSES per
MONTH
Page 17 of 45
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 SCHOOL
IF YOU ARE MOVING CLOSER TO ASMPH, WHERE WILL
YOU STAY NEXT?
AVERAGE
MONTHLY
ACTUALLY
PAID
HOW MANY DO YOU SHARE

WITH?
HOW MANY OTHERS WILL
YOU SHARE WITH?
AVERAGE
MONTHLY
UNPAID or
OWED
PROJECTED
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
11. TOTAL MONTHLY

FAMILY EXPENSES
(11A+11B+11C+11D+ 11E)
(Basic + Dorm)
Page 18 of 45
TOTAL of MONTHLY FAMILY EXPENSES for 1

year
MONTHLY X 12
MONTHS =
12. TOTAL ANNUAL FAMILY EXPENSES (In
Philippines only)
12A. TUITION PAID
2014
Please list names of who is receiving
tuition help
2014
ACTUALLY
PAID
2014
UNPAID or
OWED
PROJECTED
COSTS for
2015
1 APPLICANT
2
3
4
5
6
7
8
12B. ANNUAL NONTUITION EXPENSES
2014
ACTUALLY
PAID
2014
UNPAID or
OWED
PROJECTED
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)
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Page 19 of 45
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
PAID
2014
UNPAID or
OWED
PROJECTED
COSTS for
2015
YEARLY LOAN EXPENSES

YEARLY CREDIT CARD
EXPENSES
TOTAL DEBT
ANNUAL FAMILY INCOME &

EXPENSES BALANCE SHEET
13.
Please copy your totals and

enter them below:
TOTAL GROSS ANNUAL
2014
ACTUALL
Y PAID
2014
UNPAID
or OWED
PROJECTE
D COSTS
for 2015
Page 20 of 45
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
Page 21 of 45
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
If this is NOT
Approxima
exclusively
te
Name/brand/model for you, who Acquire Acquisitio
#
else uses it d When
n Cost
Item
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/Ov
en
Washing
Machine/
Dryer
Page 22 of 45
Air conditioner
Piano/organ
Braces
Car (fill out
section 19)
Jewelry/watch
(specify):
Other
(specify):
Other
(specify):
Other
(specify):
15. FAMILY HOUSEHOLD POSSESSIONS

DECLARATION
Please 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
When
Cost
TV sets
VHS/VCD/DVD
Stereo/Karaoke
Cellular phones
Laptop
PC
Printer
Refrigerators/
Freezers
Microwave/Oven
Washing
Machine/Dryer
Air conditioner
Page 23 of 45
Piano/organ
Other (specify):
Other (specify):
Other (specify):
16. Personal & Family Memberships

Please 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.
Acquired
Membership
For what purpose
When
Cost
17. Personal BANK ACCOUNTS

Please 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.
Type of account
(savings/checkin
Acquired
Current
Bank
g/atm)
When
balance
18. Family BANK ACCOUNTS

Please list ALL YOUR FAMILYS BANK ACCOUNTS that they
OWN or USE
Be VERY complete & clear - these details may be subject to
verification.
Page 24 of 45
Bank
Type of account
(savings/checkin
g/atm)
Who
uses the
card
Acquire
d When
Current
balance
19. Personal Credit or Debit Cards

Please 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
Who Pays the
Acquired
Current
Card
Bill
When
Credit Limit
20. Family Credit or Debit Cards

Please 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.
Current
Credit or
Who uses
Who Pays Acquired
Credit
Debit Card
the card
the Bill
When
Limit
Page 25 of 45
21. Domestic OR International Travel By YOU

Personally
OR by Your IMMEDIATE FAMILY during the past 3
YEARS
This 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

Purpose
Person(s)
(vacation
traveling &
,
relationship to emergen
you:
cy, etc.)
Dates
of trip
Destination
(s)
By
Ship
Airline
, Bus,
or Car
Estim
ated
Cost of
trip
Who
paid
for
the
trip?
22. Personal & Family Vehicle Declaration

Please 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
SHOWING
THE FRONT and SIDE of EACH VEHICLE
Make/Yr
When
Amt of
Amt Paid For
Company/
Page 26 of 45
Model
Purchased
Purchase
Family
Owned
23.
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.
Descrip
tion
Acquir Value at
Present
Yearly
and/or
Siz
ed
Acquisiti
Market
Net
use
Location
e
When
on
Value
Income
24. Siblings No Longer In School
Name
Still
Highest
residi educational
Where
Positio Annual
Civil ng attainment &
employed
n
Gross
Stat with
school
(Company & in the Income
Age us you?
attended
Location)*
Firm**
**
*If unemployed, state reason.

not leave blank.
**Do
25. Serious Acute OR Chronic Illnesses

If your monthly medical or medicine bills are P500 or greater
per month, please detail the serious medical, surgical,
Page 27 of 45
ATTACH
hospitalize# of times
d
youRelation to
physical or mental disabilities, or mental illnesses which

cause your family to spend.
Est.
Current annual
treatment treatm
Ag
/medicines ent
Name
e
Diagnosis
required cost
A SEPARATE SHEET WITH SUMMARY HISTORY OF

ILLNESS FOR EACH PATIENT
PRESENT
26. Other Dependents Living In Your House
Name
Civil Relati
Stat on to
Age us
you
Reason
for
staying
with
family
Where
Positio Annual
employed
n in
Gross
(Company &
the Income
Location)*
Firm**
**
*If unemployed, state reason.

not leave blank.
**Do
27. Relatives, Friends, Etc. Who Help

With Household & Educational Expenses
Indicate duration and extent of financial support (for whom, how much
per month/year).
When
did
Who
they
How
If they will
receiv
start
much Total
not
es
Help
for
helpin
per
per
continue,
Relation
help
what
g
month year
why
Name
to you
Page 28 of 45
28. Scholarships & Educational Plans

Are any of your siblings presently or PREVIOUSLY on
scholarship in any school :
Merit/ Athletic/
Sibling
School
Financial aid
Yes
Are YOU or any of your siblings enrolled under an education

plan in any school :
Yes
Sibling
School
Company
No
How much is
granted?
No
How much?
29. Emigration & OFW Declaration

Are any of your immediate family members under petition for
immigration or Yes
No
have any pending visa application to another country
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
No
the country for employment within the next year? Yes
If so, please indicate the names of
__________________________________________________
those who are leaving and give
__________________________________________________
brief details.
30. Working Student Declaration

If you are a working student, how many per day?
hours do you work: week?
or per
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 Medicine

Please answer the following questions as truthfully
as possible:
Are you a member of the pre-med organization?
Are you a member of any organization which
Yes
No
Yes
No
Page 29 of 45
serves poor, sick, or

hospitalized children or adults?
Have you ever joined a medical mission or
helped during any medical procedures?
Have you visited any medical schools prior to
applying to ASMPH?
Have you ever been a patient in a hospital?
Are any of your relatives actively working as
doctors?
Have you discussed the life of doctor with a doctor
relative or
your doctor or teacher?
Have you ever spent time with a doctor relative
while they practice medicine?
Have you ever spent time with a doctor or
other health professional as they do their job?
Have you ever worked in a hospital or health
center as volunteer?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
On a scale from 1 to 5, please Unrate

happy
HOW DO YOU FEEL ABOUT
1
2 3
THE FOLLOWING:
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
Very
Confid
ent
5
Page 30 of 45
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:

4
Willing
to give
up
N
A
going to gimmicks or parties
reading non medical literature
watching TV or DVDs
Seeing your family as often?
Won't
give up
Your boyfriend/girlfriend?
Your weekends?
Your co-curriculars or orgs or
non-worship church activities?
going to movies
On a scale from 1 to 5,
How much do your parents
WANT you to go to medical
school?
How IMPORTANT is it to
your parents
that you become a doctor?
How much did your
PARENTS Influence you to
become a doctor?
How much did your
CLASSMATES or COURSE
influence you
to become a doctor?
How OFTEN do you have
DOUBTS
about going to medical
school?
How STRONG is your
COMMITMENT
please rate the following:

Against
my
going
TOTALLY
determi
ned
Not
import
ant
Very
importa
nt
No
influen
ce
Highly
influenc
ed
Highly
influenc
ed
Frequen
t
doubtful
No
influen
ce
No
doubts
Unsure
if I'll
finish)
Totally
committ
ed
Page 31 of 45
to FINISHING medical
school?
How much you REALLY Will go
if
want to go to medical accept
school?
ed
totally
determi
ned
How long have you wanted to become a doctor? Please

explain briefly below:
Do you plan to have a family?

Do you wish to travel during or after medical
school?
Have you ever thought about starting a
business?
Are you willing to practice in your province
after graduation or residency?
Yes
No
Yes
No
Yes
No
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 INFORMATION

List any physical problems that should be taken into
consideration in planning your program of studies and school
Page 32 of 45
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 You

List 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 needs
You 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.)
Page 33 of 45
Type your ESSAY here:
Page 34 of 45
35. SOFT OR HARD COPIES OF PICTURES OF

CARS, HOMES, DORM, ETC (label each clearly)
Paste soft copies of picture here
Pix label =
Pix label =
Pix label =
Pix label =
Page 35 of 45
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Page 36 of 45
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Pix label =
Page 37 of 45
Pix label =
Pix label =
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Page 38 of 45
Pix label =
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Page 39 of 45

Financial 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
Page 40 of 45
Page 41 of 45

APPLICANTS FINANCIAL AUTHORIZATION FORM 2015 2016

APPLICANT NAME __________________________________________________________________________
Last Name
I, _____________________________________,
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.
First Name
Middle Name
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
Page 42 of 45
________________________________________________________
_
Applicants Signature over printed name
Date
Page 43 of 45

PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 2015 2016

APPLICANT NAME __________________________________________________________________________
Last Name
I/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
First Name
Middle Name
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
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.
Page 44 of 45
___________________________________________
Parent/Guardians Signature over printed name / Date
_____________________________________
Parents Signature over printed name / Date

Asmph Fa Application - New Student - 2015-16 Final

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Ateneo de Manila University

School of Medicine and Public Health

Financial Aid Application Form

filled out by the APPLICANT

2. Submit the following

use your ADMISSION

13th month pay allowances)

ii. EACH VEHICLE

b. If parents are selfemployed, please submit a

If not available, please

Residences, houses, dorm rooms, lots, etc

Parents and/or Applicants Certificate of employment OR Parents and/or

Last name, first, MI

BIR I.T.R. FOR 2014

TO: ASMPH Financial Aid

Last name, first name, MI

Ateneo de Manila University

Financial Aid Application Form SY 2015 - 2016

Nickname ____________________ School

Degree _______________________________________________________Date of graduation

where highest grade is

[ ] Yes, I graduated/expect to graduate:

ASMPH Financial Aid APPLICATION NEW 2015-16

How many do you share with?

Is he the Primary Wage earner of

ASMPH Financial Aid APPLICATION NEW 2015-16

Highest educational attainment

If employed, name of company/employer

Is she the Primary Wage earner

Highest educational attainment

If employed, name of company/employer

Is he/she responsible for your financial

Highest educational attainment

If employed, name of company/employer

SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a

Attach a separate sheet if needed

APPLICANT ACADEMIC INFORMATION

List any HONORS OR PRIZES you have received for academic

Attach a separate sheet if needed

List your college extra-curricular activities, including positions held or

List your community and / or church activities. Attach a separate

Other work experience after graduation from College - Attach a

Company and Address

Were you ever dismissed, suspended or placed on probation?

If Yes, specify dates, offenses, penalties

Total FAMILY INCOME Per Year

If A PARENT or SIBLING SENDS MONEY from outside the Philippines,

6A. FAMILY INCOME

6B. Support from

ASMPH Financial Aid APPLICATION NEW 2015-16

6C. PROFITS EARNED

6D. INTEREST INCOME FROM INVESTMENTS

6E. Other LOCAL

REQUIRED Additional INFORMATION ABOUT

THIS INCLUDES SUPPORT RECEIVED BY THE APPLICANT from PART/FULL TIME

Name of employer, relative,

7. Total APPLICANT INCOME for

This includes money borrowed FOR LIVING EXPENSES from

Borrowed from FAMILY

Borrowed from BANKS (specify each)

Borrowed using CREDIT CARDS (specify each)

8. Total LOANS FOR LIVING for

GROSS ANNUAL INCOME SUMMARY

6A. FAMILY INCOME (page 8)