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 FAMILY’S
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
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
Page 1 of 37
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 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
Registrar’s 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
 Parents and/or Applicant’s Certificate of employment OR Parents and/or
Applicant’s Self-employed Business description & balance sheets or
Retirement or retrenchment information
 BIR I.T.R. FOR 2014
Last name, first, MI
 Legal size brown envelope
 Applicant’s Name in TOP LEFT corner as
“Last name, first name, MI”
TO: ASMPH Financial Aid Committee
Registrar’s Office, ASMPH ,
Ortigas Ave. 1604, Pasig City Page 2 of 37
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
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
AT THE BACK)
LEGAL NAME ________________________________________________________________________________
(Name in Birth Certificate)
Last Name
First Name
Middle Name
Nickname ____________________ School ________________________________________________________
Degree _______________________________________________________Date of graduation ______________
where highest grade is equivalent to  4  5  1
Cumulative QPI/GPA
NMAT
% taken when
Part I
Inductive
Reasoning
Physics
Verbal
Biology
₅₆Are you graduating with [ ] No
HONORS?
%
Part I
%
Perceptual
Acuity
Chemistry
Quantitative
Social Science
[ ] Yes, I graduated/expect to graduate:
[ ] Summa Cum Laude
[ ] Magna Cum Laude
[ ] Cum Laude
[ ] Honorable Mention
1. SCHOLARSHIP REQUEST
₂ PERCENTAGE
GRANT
REQUESTED
100% TF
50% TF
90% TF
40% TF
80% TF
30% TF
70% TF
20% TF
₃ If you are NOT granted financial aid, will you continue in ASMPH?
₄If you received financial aid in COLLEGE,
how much did you receive? (check all that apply)
[ ] Yes
60% TF
10% TF
[ ] No
100TF 75TF 50TF 25TF _____
Dorm Books Food _________
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 3 of 37
2. PERSONAL INFORMATION
₇Permanent Street No.
Address
Street
Subdivision/Barangay
Province
₈Mailing Address
Street No.
(If not the same as
permanent add.)
Country
Street
₁₂E-mail
Address(s)
Street
ZIP code
Subdivision/Barangay
City/Municipality
ZIP code
[ ] relatives
[ ] a boarding house/dorm
[ ] house/condo/apartment
[ ] other ___________________
How many do you share with? ________
Residence
(
)
Office
Area Code
Mobile No. 1
(
(
)
Area Code
)
Mobile No. 2
Area Code
1. ________________________________________________
₁₅Age
(
)
Area Code
₁₃Gender
2. ________________________________________________
₁₄Date of Birth
(MM/DD/YEAR)
₁₇Citizenship [ ] Filipino
₁₉Civil Status [ ] Single
₂₁If married,
name of spouse
City/Municipality
Country
₉LOCAL Address
where you stay
during school Street No.
₁₁Applicant’s
phone
Numbers
ZIP code
Subdivision/Barangay
Province
₁₀You live with/in
City/Municipality
[ ] Male
[ ] Female
₁₆Place of Birth
[ ] Others, pls. specify
[ ] Married
[ ] Separated
₁₈PhilHealth [ ] YES [ ] NO
₂₀Blood Type
[ ] Widowed
Age
Last Name
First Name
Contact No. Mobile No.
Middle Name
Address
if different
(
)
Area Code
3. FAMILY INFORMATION
FATHER
23Is
₂₂PLEASE INDICATE IF:
[ ] SINGLE PARENT
he the Primary Wage earner of Family
₂₅Father’s Name
Last Name
[ ] SEPARATED
Street
Province
Middle Name
Subdivision/Barangay
City/Municipality
Country
ZIP code
Residence
(
)
Area Code
Office
(
)
Area Code
Mobile
No. 1
(
)
Area Code
Mobile
No. 2
(
)
Area Code
ASMPH Financial Aid APPLICATION – NEW – 2015-16
[ ] DECEASED
24Age
[ ] YES [ ] NO
First Name
₂₆Father’s Street No.
Address
₂₇Father’s
Telephone
Numbers
[ ] WIDOWED
Page 4 of 37
₂₈Father’s e-mail
Address(s)
1. ____________________________________
2. ____________________________________
Highest educational attainment ______________________________________________
₂₉Father’s School/course/years attended or graduated ____________________________________
education Year Graduated __________ Degree _________________________________________
PRC Board exam in __________________ taken when ________
Passed [ ] yes [ ] no
If employed, name of company/employer ______________________________________
Location of employer_______________________________________________________
₃₀Father’s Position in firm ________________________________
Years in firm ______________
employment /
Annual gross salary in the firm ___________________
earning capacity [ ] Regular or [ ] Contractual
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
MOTHER
₃₁PLEASE INDICATE IF:
[ ] SINGLE PARENT
₃₂Is she the Primary Wage earner of Family
₃₄Mother’s
Name Last Name
Street
Province
₃₇Mother’s email Address(s)
[ ] SEPARATED
Middle Name
subdivision/Barangay
Country
City/Municipality
ZIP code
Residence
(
)
Area Code
Office
(
)
Area Code
Mobile
No. 1
(
)
Area Code
Mobile
No. 2
(
)
Area Code
1. ____________________________________
[ ] DECEASED
₃₃Age
[ ] YES [ ] NO
First Name
₃₅Mother’s Street No.
Address
₃₆Mother’s
Telephone
Numbers
[ ] WIDOWED
2. ____________________________________
Highest educational attainment ______________________________________________
₃₈Mother’s School/course/years attended or graduated ____________________________________
education Year Graduated __________ Degree _________________________________________
PRC Board exam in __________________ taken when ________
Passed [ ] yes [ ] no
If employed, name of company/employer ______________________________________
Location of employer_______________________________________________________
₃₉Mother’s Position in firm ________________________________
Years in firm ______________
employment /
Annual gross salary in the firm ___________________
earning capacity [ ] Regular or [ ] Contractual
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
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 5 of 37
GUARDIAN
₄₀RELATIONSHIP TO YOU:
(If applicable)
₄₁ Is he/she responsible for your financial needs :
₄₃Guardian’s
Name
Last Name
₃₅Guardian’s
Street No.
₄₂Age
[ ] YES [ ] NO
First Name
Street
Middle Name
Subdivision/Barangay
City/Municipality
Address
Province
Residence
₃₆Guardian’s
Telephone
Numbers
(
Country
ZIP code
)
Office
Area Code
Mobile
No. 1
₃₇Guardian’s
e-mail Address(s)
(
(
)
Area Code
Mobile
No. 2
)
Area Code
1. ____________________________________
(
)
Area Code
2. ____________________________________
Highest educational attainment ______________________________________________
School/course/years attended or graduated ____________________________________
₄₇Guardian’s
education
Year Graduated __________
Degree _________________________________________
PRC Board exam in __________________ taken when ________
Passed [ ] yes [ ] no
If employed, name of company/employer ______________________________________
Location of employer_______________________________________________________
₄₈Guardian’s
employment /
earning capacity
Position in firm ________________________________
[ ] Regular or [ ] Contractual
Years in firm ______________
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
₄₉Person to Contact
in case of
emergency
₅₀Emergency
Contact Address
₅₁Emergency Contact
Telephone Numbers
[ ] Father
[ ] Mother
[ ] Guardian
[ ] Spouse
[ ] Other (please specify name) ________________________________________
Street No.
Province
)
Reside (
Area
Code
nce
)
Mobile (
Area
Code
No. 1
Street
Subdivision/Barangay
City/Municipality
Country
Office
ZIP code
(
)
Area Code
Mobile No. 2
(
)
Area Code
₅₂SIBLING’S EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 6 of 37
NAME
Age
School last attended
Year Level
Course
Graduated
Attach a separate sheet if needed
4. APPLICANT ACADEMIC INFORMATION
₅₄SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)
Levels
Attended
Elementary
School
Address
Period Covered
Levels
Attended
High School
Address
Period Covered
College
Yr. _____ To ______
20 _____ to 20 ______
Degree
Address
Post Graduate
(Including other
College of
Medicine)
Gr. _____ To ______
19 _____ to 20 ______
Period Covered
20 _____ to 20 ______
Degree
Address
Period Covered
20 _____ to 20 ______
₅₅List 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. 2 nd
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 ACTIVITIES
₅₇List 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
₅₈List your community and / or church activities. Attach a separate sheet if needed
₅₉Other work experience after graduation from College - Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 7 of 37
Position
Company and Address
Date
₆₀Were 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 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
SUB-TOTAL
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
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 8 of 37
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 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
RECEIVED
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
2015
__________________________________
__________________________________
6E. OTHER INCOME Sub-total
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 9 of 37
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
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.
Total 2014
Amount
Borrowed
LENDER
Total still
UNPAID or
OWED
PROJECTED
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
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 10 of 37
9. TOTAL GROSS ANNUAL INCOME SUMMARY
2014 INCOME
INCOME
PLEASE COPY THE TOTALS
ACTUALLY
UNPAID or
FROM ABOVE
RECEIVED
OWED
PROJECTED
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
INCOME
UNPAID or
OWED
PROJECTED
INCOME for
rest of 2015
Father
Mother
Brothers
Sisters
Other
Other
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 11 of 37
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
PROJECTED
OWED
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 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
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 12 of 37
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
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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
AVERAGE
MONTHLY PAID
(please identify CARD)
AVERAGE
PROJECTED
MONTHLY
MONTHLY
UNPAID BALANCE 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
PAID
2014 UNPAID
or OWED
PROJECTED
COSTS for 2015
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11D. Sub-total other monthly payments
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 13 of 37
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 SCHOOL
HOW 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
AVERAGE
PROJECTED
MONTHLY
MONTHLY
COSTS for 2015
ACTUALLY PAID UNPAID or OWED
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 = 

ASMPH Financial Aid APPLICATION – NEW – 2015-16


Page 14 of 37
12. TOTAL ANNUAL FAMILY EXPENSES (In Philippines only)
2014 ACTUALLY 2014 UNPAID
PROJECTED
12A. TUITION PAID 2014
Please list names of who is receiving tuition help
PAID
or OWED
COSTS for 2015
2014 UNPAID
or OWED
PROJECTED
COSTS for 2015
1 APPLICANT
2
3
4
5
6
7
8
Attach a separate sheet if needed
12B. ANNUAL NON-TUITION
EXPENSES
2014 ACTUALLY
PAID
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) =
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 15 of 37
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
13.
ANNUAL FAMILY INCOME & EXPENSES
BALANCE SHEET
Please copy your totals and
enter them below:
2014
ACTUALLY
PAID
TOTAL GROSS ANNUAL INCOME 
+
from page 11 above
TOTAL ANNUAL EXPENSES  -from bottom of page 15 above
2014
UNPAID or
OWED
PROJECTED
COSTS for
2015
+
+
--
--
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
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 16 of 37
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
Item
Name/brand/model #
If this is NOT
exclusively for
you, who else
uses it
Acquired
When
Approximate
Acquisition
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
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 17 of 37
Car (fill out section
19)
Jewelry/watch
(specify):
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
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
Piano/organ
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 18 of 37
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.
Membership
For what purpose
Acquired When
Cost
Attach a separate sheet if needed
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
Bank
(savings/checking/atm) Acquired When Current balance
Attach a separate sheet if needed
18. Family BANK ACCOUNTS
Please list ALL YOUR FAMILY’S BANK ACCOUNTS that they OWN or USE
Be VERY complete & clear - these details may be subject to verification.
Type of account
Who uses
Acquired
Current
(savings/checking/atm)
the card
When
balance
Bank
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 19 of 37
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.
Current Credit
Credit or Debit Card
Who Pays the Bill
Acquired When
Limit
Attach a separate sheet if needed
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.
Credit or Debit
Who uses the Who Pays the
Acquired
Current Credit
Card
card
Bill
When
Limit
Attach a separate sheet if needed
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
Person(s) traveling
& relationship to
you:
Purpose
(vacation,
emergency,
etc.)
Dates of
trip
Destination(s)
ASMPH Financial Aid APPLICATION – NEW – 2015-16
By Ship
Airline,
Bus,
or Car
Estimated
Who
Cost of
paid for
trip
the trip?
Page 20 of 37
Attach a separate sheet if needed
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 Model
When Purchased
Amt of Purchase
Amt Paid For
Company/
Family Owned
Attach a separate sheet if needed
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.
Description
and/or use
Location
Size
Acquired
When
Value at
Acquisition
Present
Market Value
Yearly Net
Income
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – 2015-16
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24. Siblings No Longer In School
Name
Still
Highest
residing educational
Civil with
attainment &
Age Status you? school attended
Attach a separate sheet if needed
Where employed Position Annual
(Company &
in the
Gross
Location)*
Firm** Income**
*If unemployed, state reason.
**Do not leave blank.
25. Serious Acute OR Chronic Illnesses
Age
Diagnosis
# of times
hospitalized
Name
Relation to
you
If 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.
Current
Est.
treatment annual
/medicines treatme
required
nt cost
ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENT
Attach a separate sheet if needed
26. Other Dependents Living In Your House
Name
Reason for Where employed
Civil Relation staying with
(Company &
Age Status to you
family
Location)*
Attach a separate sheet if needed
*If unemployed, state reason.
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Position Annual
in the
Gross
Firm** Income**
**Do not leave blank.
Page 22 of 37
27. Relatives, Friends, Etc. Who Help
With Household & Educational Expenses
Indicate duration and extent of financial support (for whom, how much per month/year).
Who
receives
Relation to
help
you
Name
Help for
what
When did How
Total
they start much per per
helping month
year
If they will not
continue, why
Attach a separate sheet if needed
28. Scholarships & Educational Plans
Are any of your siblings presently or PREVIOUSLY on scholarship in any school :
Merit/ Athletic/
Sibling
School
Financial aid
Yes
How much is granted?
Yes
Are YOU or any of your siblings enrolled under an education plan in any school :
Sibling
School
No
Company
No
How much?
Attach a separate sheet if needed
29. Emigration & OFW Declaration
Are 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.
__________________________________________________
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
Yes No
the country for employment within the next year?
__________________________________________________
30. Working Student Declaration
If 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?
ASMPH Financial Aid APPLICATION – NEW – 2015-16
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31. Your Experience with Medicine
Please answer the following questions as truthfully as possible:
 Yes
 No
 Yes
 No
 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
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Are you a member of the pre-med organization?
Are you a member of any organization which serves poor, sick, or
hospitalized children or adults?
Have you ever joined a medical mission or
helped during any medical procedures?
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?
On a scale from 1 to 5, please rate
HOW DO YOU FEEL ABOUT THE FOLLOWING:
Unhappy
Very
Confident
1
2
3
4
5
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

 



 



 


ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 24 of 37
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 up
2
3
4
Willing to
give up
NA
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 parents Against
1
2
3
4
WANT you to go to medical school? my going
How IMPORTANT is it to your parents
Not
1
2
3
4
that you become a doctor? important
How much did your PARENTS
No
1
2
3
4
Influence you to become a doctor? influence
How much did your CLASSMATES or
No
COURSE influence you influence 1 2 3 4
to become a doctor?
How OFTEN do you have DOUBTS
No doubts 1
2
3
4
about going to medical school?
How STRONG is your COMMITMENT Unsure if
1
2
3
4
to FINISHING medical school? I'll finish)
How much you REALLY Will go if
1
2
3
4
want to go to medical school? accepted
5
TOTALLY
determined
5
Very
important
5
Highly
influenced
5
Highly
influenced
5
Frequent
doubtful
5
Totally
committed
5
totally
determined
How long have you wanted to become a doctor? Please explain briefly below:
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 25 of 37
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 INFORMATION
List 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 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
_____________________________________________________________________________
_____________________________________________________________________________
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 26 of 37
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 family’s 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.)
Type your ESSAY here:
ASMPH Financial Aid APPLICATION – NEW – 2015-16
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ASMPH Financial Aid APPLICATION – NEW – 2015-16
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ASMPH Financial Aid APPLICATION – NEW – 2015-16
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35. SOFT OR HARD COPIES OF PICTURES OF
CARS, HOMES, DORM, ETC (label each clearly)
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ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 34 of 37
Ateneo de Manila University
School of Medicine and Public Health
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.
________________________________________________________
Applicant’s Signature
Date
________________________________________________________
Parent’s or Guardian’s Signature
Date
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 35 of 37
Ateneo de Manila University
School of Medicine and Public Health
APPLICANT’S FINANCIAL AUTHORIZATION FORM 2015 – 2016
APPLICANT NAME __________________________________________________________________________
(Name in Birth Certificate)
Last Name
First 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.
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
_________________________________________________________
Applicant’s Signature over printed name
Date
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 36 of 37
Ateneo de Manila University
School of Medicine and Public Health
PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 2015 – 2016
APPLICANT NAME __________________________________________________________________________
(Name in Birth Certificate)
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 child’s 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.
First Name
Middle Name
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.
I/WE consent to the use and disclosure by the Ateneo
___________________________________________
Parent/Guardian’s Signature over printed name / Date
_____________________________________
Parent’s Signature over printed name / Date
ASMPH Financial Aid APPLICATION – NEW – 2015-16
Page 37 of 37