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APPLICATION FOR ADMISSION SY 20__ - 20__

Application no.: __________________________


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 Name

First Name

Middle Name

Nickname ________________ School ______________________________________


Degree ________________________________________________________________

Recent
2 x 2
Photo of
Applicant
Photo Guidelines:

Red Background

Colored

Full face, front view

Attire: collared shirt with sleeves

Taken within the past 6 months

Digitally-altered photos are not


accepted

PERSONAL INFORMATION
. Permanent Address

. Mailing Address

Street No.

Street No.

(If not the same as the permanent


address)

(
. Telephone Numbers

Residence

(MM/DD/YEAR)

. Citizenship
. Civil Status
. If married, name of
spouse

Subdivision/Barangay

City/Municipality

Province

Country

ZIPcode

Street

Subdivision/Barangay

City/Municipality

Province

Country

ZIPcode

Office

Area Code

Fax

. E-mail Address
. Date of Birth

Street

Mobile No.

Area Code

. Gender

[ ] Filipino
[ ] Single

. Age

Area Code

Area Code

[ ] Male

[ ] Female

. Place of Birth

[ ] Others, pls. specify


[ ] Married
[ ] Separated

[ ] Widowed

. Religion
. Blood Type
Mobile No.

Contact No.
Last Name

First Name

Area Code

Middle Name

FAMILY INFORMATION
. Fathers Name

Living

Deceased

If College Graduate, from what school? _____________________________________________


Year Graduated _________________ Degree _______________________________________
If employed, name of company/employer ____________________________________________
. Mothers Name

. Guardians Name /
Person to contact in case
of emergency

Living

Deceased

If College Graduate, from what school? _____________________________________________


Year Graduated _________________ Degree _______________________________________
If employed, name of company/employer ____________________________________________
Relation
Contact Number
Name
(
)
Last Name

First Name

Middle Name

Area Code

PLEASE DO NOT WRITE BELOW THIS LINE FOR ADMISSIONS OFFICE ONLY
OFFICIAL RECEIPT NO.: _______________
AMOUNT PAID:
_______________

GWA/QPI: ______________ / _________ ___


NMAT PERCENTILE RANK: ________________

LEGAL NAME

______________________________________________________________________________

(Married Name, if applicable)

Last Name

First Name

. Have you taken the NMAT?

[ ] Yes
If yes, list all exam dates and results below
Date
Standard Score
(MM/DD/YEAR)

Middle Name

[ ] No
Percentile Rank

Testing Center

. SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest)

Name

Name

School last attended

Year Level

Course

Graduated

. Do you have any relatives who have attended or are attending Ateneo de Manila?
Relation
Level/Year & Course

Graduated

ACADEMIC INFORMATION
. SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)
Elementary
School
Address
High School

Address
College

Levels Attended

Gr. _____ To _____ __

Period Covered

Yr._____ To Yr.______

Levels Attended

Yr. _____ To Yr._____

Period Covered

Yr. _____ To Yr._____

Degree
Address

Post Graduate

Period Covered

Yr. _____ To Yr._____

Degree

(Including other
College of Medicine)

Address

Period Covered

Yr. _____ To Yr. _____

LEGAL NAME
(Married Name, if applicable)

______________________________________________________________________________
Last Name

First Name

Middle Name

. 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.
Are you graduating with Honors? No
Yes, I graduated/expect to graduate: Summa Cum Laude Magna Cum Laude
Cum Laude
Honorable Mention

. Were you ever dismissed, suspended or placed on probation?


Yes, (Please specify dates, offenses, penalties) _____________________________________________________________
No

EXTRA-CURRICULAR ACTIVITIES
. 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)

If you are a member of your schools varsity team, what is your skill level (please check):
Average
High

Superior
. List your community and / or church activities.

. Other work experience after graduation from College


Position
Company and Address

Date

OTHER INFORMATION
. Physical Fitness. List any physical defects 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. Yes No

LEGAL NAME
(Married Name, if applicable)

______________________________________________________________________________
Last Name

First Name

Middle Name

. Name the schools to which you have applied or intend to apply, local or foreign including ASMPH.
Priority
Name of School

1st
2nd
3rd
4th
5th
. Give the names of the persons recommending you. NOTE: One (1) recommendation letter must come from each of the following: the
Dean/College Secretary of your school and your Department Chair. In the absence of one, a senior a recommendation letter from a Senior
Professor will be accepted.
1) Dean / College Secretarys Name
2)

Department Chairs Name

3)

Others: Please write Name:

. Financial Aid / Scholarship.


Are you applying for Financial Aid / Scholarship?

[ ] Yes,
Please attach your accomplished Financial Aid form and requirements. Application form may be downloaded from the ASMPH website

[ ] No

PERSONAL ESSAY
. In order for the Admission Committee and Scholarship Committee to get to know you better, write an essay about what
is the role of the doctor as a professional in todays world? (Guidelines: 3 pages short bond paper, double-spaced, Times
New Roman font, 12pt.)

APPLICATION FOR ADMISSION

I hereby certify that all information written in this application is complete and accurate. I agree
if accepted as a student 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

Do not write below this line.