Documente Academic
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INSTRUCTIONS
1. This application should be filled out NOT use your ADMISSION
by the APPLICANT & his/her ESSAY or SIMPLY ASK FOR
PARENTS together. ALL FINANCIAL AID. You must explain
QUESTIONS must be answered WHY YOU NEED HELP so
carefully and completely. If you do not include details of the FAMILYS
completely fill this application out, it will FINANCIAL SITUATION as part
not be processed. of the explanation. This ESSAY
MUST BE COMPLETE AND
2. Submit the following NOW:
TRUTHFUL.
This FA APPLICATION FORM
b. PHOTOS (either HARD COPIES
INCLUDING:
or SOFT COPY pasted below) of
a. Your completed DETAILED personal or family assets. These
PERSONAL NEEDS ESSAY by must be LABELED and attached
the APPLICANT at the bottom of at the end of this application
this form explaining WHY YOU
NEED FINANCIAL AID. Do
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i. PERMANENT and LOCAL employed parent and sibling of the
HOUSES/APARTMENTS/ applicant still residing with the
CONDOS/ FARMS / etc. family;
(whether owned, borrowed, If parents are self-employed, please submit
loaned, or rented) where you stay a detailed description of the
showing the OUTSIDE (FRONT,
BACK, SIDES) of the HOUSE or b. business and an income & expense
apartment as well as the ROOMS financial statement for the year;
INSIDE. c. If parents were retired or
ii. EACH VEHICLE (whether RETRENCHED IN the past three
owned, borrowed, loaned, or years, please submit a copy of
rented) showing the FRONT and certification indicating amount of
SIDE of EACH VEHICLE retirement or separation benefits, if
received.
iii. EACH PROPERTY, LOT, or
HOUSE (other than d. Latest income tax return for each
PERMANENT or LOCAL employed/self-employed parent of
RESIDENCES) (whether applicant. If not available, please
owned, borrowed, loaned, or explain in your PERSONAL ESSAY;
rented) SHOWING the e. Copies of the following:
OUTSIDE (front, back, sides) of
i. Electricity bill
the HOUSE or PROPERTY as well
as the ROOMS inside the house. ii. Water bill
DOCUMENTS CHECKLIST:
THIS Financial Aid Application WITH
TO: ASMPH Scholarship Committee
Personal Needs Essay written by the Applicant AND
Registrars Office, ASMPH ,
Photos of: Residences, houses, dorm rooms, lots, etc Vehicles
Ortigas Ave. 1604, Pasig City
Parents and/or Applicants Certificate of employment OR Parents and/or
Applicants Self-employed Business description & balance sheets or
Retirement or retrenchment information
BIR I.T.R. FOR 2016
Legal size brown envelope
Applicants Name in TOP LEFT corner as
Last name, first name, MI
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Financial Aid Application Form SY 20_ - 20_
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 Please PASTE a
ANNUALLY. ANY FINANCIAL AID GRANT = TUITION & FEES COST FAMILY SOFT or HARD copy of
CONTRIBUTION. ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF Recent 2 x 2 Photo of
THE BURDEN AS POSSIBLE. The Applicant
(IF HARD COPY, PLEASE
Please PRINT or TYPE. Credentials filed in support of this application become the WRITE YOUR NAME
property of the Ateneo de Manila University and are NOT returnable to the applicant. AT THE BACK)
Misrepresentation of Information requested in this application will be considered
sufficient reason for refusal of admission and exclusion.
1. SCHOLARSHIP REQUEST
PERCENTAGE GRANT
100% TF 75% TF 50% TF 25% TF
REQUESTED
If you are NOT granted financial aid, will you continue in ASMPH? [ ] Yes [ ] No
If you received financial aid in COLLEGE, 100TF 75TF 50TF 25TF _____
how much did you receive? (check all that apply) Dorm Books Food _________
2. PERSONAL INFORMATION
Mailing Address
(If not the same Street No. Street Subdivision/Barangay City/Municipality
as permanent
add.)
Province Country ZIP code
LOCAL Address
where you stay
during school Street No. Street Subdivision/Barangay City/Municipality ZIP code
1. ________________________________________________
E-mail [ ] Male
Gender
Address(s) 2. ________________________________________________ [ ] Female
Date of Birth
Age Place of Birth
(MM/DD/YEAR)
Citizenship [ ] Filipino [ ] Others, pls. specify [ ] YES
PhilHealth
[ ] NO
Civil Status [ ] Single [ ] Married [ ] Separated [ ] Widowed Blood Type
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If married,
name of Age
spouse Last Name First Name Middle Name
Mobile No. Address
Contact No. ( ) if different
Area Code
3. FAMILY INFORMATION
FATHER PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED
23Is he the Primary Wage earner of Family [ ] YES [ ] NO 24Age
Fathers Name
Last Name First Name Middle Name
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MOTHER PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED
Is she the Primary Wage earner of Family [ ] YES [ ] NO Age
Mothers
Name Last Name First Name Middle Name
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Guardians Residence ( ) Office ( )
Area Code Area Code
Telephone
Numbers Mobile Mobile
No. 1
( ) No. 2
( )
Area Code Area Code
Guardians
1. ____________________________________ 2. ____________________________________
e-mail Address(s)
Highest educational attainment ______________________________________________
Guardians School/course/years attended or graduated ____________________________________
education Year Graduated __________ Degree _________________________________________
PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no
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Attach a separate sheet if needed
List any HONORS OR PRIZES you have received for academic excellence in 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
5. 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) Attach a separate
sheet if needed
List your community and / or church activities. Attach a separate sheet if needed
Other work experience after graduation from College - Attach a separate sheet if needed
Position Company and Address Date
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Were you ever dismissed, suspended or placed on probation? [ ] Yes [ ] No
If Yes, specify dates, offenses, penalties ______________________________________________
Please attach a separate sheet explaining the circumstances
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Attach a separate sheet if needed
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6E. Other LOCAL Income 2016 INCOME INCOME PROJECTED
ACTUALLY UNPAID or INCOME for
(specify): RECEIVED OWED 2017
__________________________________
__________________________________
6E. OTHER INCOME Sub-total
Attach a separate sheet if needed
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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 2016 Total still PROJECTED
Amount UNPAID or LOANS for
LENDER Borrowed OWED 2016
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
___________________________________
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8. Total LOANS FOR LIVING for 2016
Attach a separate sheet if needed
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2016 GROSS PROJECTED
FOREIGN UNPAID or INCOME for
INCOME OWED rest of 2017
Father
Mother
Brothers
Sisters
Other
Other
Attach a separate sheet if needed
11B. MONTHLY LOAN PAYMENTS (banks, SSS, PagIbig, family, friends etc)
2016 PROJECTED
(please identify to whom/why paid and if 2016 UNPAID or
ACTUALLY COSTS for
loan is for business) OWED
PAID 2017
Mortgage Amortization
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11B. Sub-total for MONTHLY loan
payments
Attach a separate sheet if needed
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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
PROJECTED
AVERAGE AVERAGE
MONTHLY
(please identify CARD) MONTHLY MONTHLY
COSTS for
PAID UNPAID BALANCE
2017
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11C.Sub-total for MONTHLY
credit card payments
Attach a separate sheet if needed
2016 PROJECTED
11D. Other Monthly Payments ACTUALLY
2016 UNPAID or
COSTS for
(please identify to whom/why paid) OWED
PAID 2017
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11D. Sub-total other monthly payments
Attach a separate sheet if needed
IF YOU ARE MOVING CLOSER TO ASMPH, WHERE WILL YOU STAY NEXT? HOW MANY OTHERS WILL
YOU SHARE WITH?
AVERAGE AVERAGE
PROJECTED
MONTHLY MONTHLY UNPAID
COSTS for 2017
ACTUALLY PAID 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
Photocopying, etc.
Internet in dorm or broadband
Books
____________________________________________
____________________________________________
11E. Sub-total for DORM EXPENSES
Attach a separate sheet if needed
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TOTAL of MONTHLY FAMILY EXPENSES for 1 year
MONTHLYX 12 MONTHS =
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SURPLUS/ LOSS FOR THE YEAR
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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
exclusively for Approximate
you, who else Acquired Acquisition
Item Name/brand/model # uses it When Cost
Laptop
Desktop PC / Tablet
Printer
External Hard Drive
Cellular phone1
Cellular phone2
Cellular phone3
DSL line
Pocket Wifi
Digital recorder
Broadband account
Audio recorder
TV set(s)
VHS/VCD/DVD
Refrigerators/
Freezers
Microwave/Oven
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Washing Machine/
Dryer
Air conditioner
Piano/organ
Braces
Car (fill out section
19)
Jewelry/watch
(specify):
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
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Microwave/Oven
Washing
Machine/Dryer
Air conditioner
Piano/organ
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
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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
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Attach a separate sheet if needed
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24. Siblings No Longer in School
Still Highest
residing educational Where employed Position Annual
Civil with attainment & (Company & in the Gross
Name Age Status you? school attended Location)* Firm** Income**
Attach a separate sheet if needed *If unemployed, state reason. **Do not leave blank.
ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENT
Attach a separate sheet if needed
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Attach a separate sheet if needed *If unemployed, state reason. **Do not leave blank.
Are YOU or any of your siblings enrolled under an education plan in any school : Yes No
Sibling School Company How much?
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Un- Very
On a scale from 1 to 5, please rate happy Confident
HOW DO YOU FEEL ABOUT THE FOLLOWING:
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
Active participation in activities of the Scholars
Society and activities for the Bigay Pugad
Scholarship Fund
5 year mandatory service requirement in the
Philippines for ASMPH scholars
ASMPH Scholar requirement to voluntarily update
information in ASMPH Graduate database and find
support for a new ASMPH scholar within 20 years
after ASMPH graduation
Your boyfriend/girlfriend?
Your weekends?
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non-worship church activities?
going to movies
watching TV or DVDs
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How long have you wanted to become a doctor? Please explain briefly below:
Please list all the medical schools have you applied to and rank them from first choice to last?
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Have you ever been forced to stop schooling for a month or more because of poor
health? Give details and dates.
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Type your ESSAY here:
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35. SOFT OR HARD COPIES OF PICTURES OF
CARS, HOMES, DORM, ETC (label each clearly)
Paste soft copies of picture here Paste soft copies of picture here
Paste soft copies of picture here Paste soft copies of picture here
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I/we hereby certify that all information written in this application is complete and
accurate and we are hereby authorized to verify the same.
________________________________________________________
Applicants Signature Date
________________________________________________________
Parents or Guardians Signature Date
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APPLICANTS FINANCIAL AUTHORIZATION FORM 20__ 20__
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Applicants Signature over printed name Date
PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 20_ 20____
APPLICANT NAME __________________________________________________________________________
(Name in Birth Certificate) Last Name First Name Middle Name
I/WE, _____________________________________, I/WE consent to the use and disclosure by the Ateneo of
hereby certify that all information provided in our information in and relating to our application, to any of its
application or submitted in support of this subsidiaries and affiliates, agents, banks and banking
application is complete and accurate. associations, credit card companies and associations,
financial institutions, credit information bureaus and their
I/WE uring the period of any grant given
equivalent, third-party service providers rendering
understand that misrepresentation of information
services to the Ateneo, as well as third parties authorized
or withholding of information requested for this
by the ASMPH to receive such information, wherever
application will be considered reason for
situated, for confidential use in connection with the
disapproval/cancellation of financial aid and,
exercise of its functions to provide financial aid (including
where appropriate, grounds for legal action, as
but not limited to credit investigation and collection,
well as referral to the Dean for charges of
information technology systems and processes, data
Academic Dishonesty with the potential of
processing, imaging and storage, back-up and recovery
Dishonorable Dismissal with mandatory
and risk analyses purposes).
repayment of all grant monies paid.
I/WE hereby authorize the Ateneo School of I/WE agree that such disclosure or exchange of
Medicine and Public Health (ASMPH) to confirm information shall not be the basis of any claim against
through investigation any information provided by the School or the parties to whom the School makes
for our application for ASMPH financial aid from the disclosure.
whatever sources the school may consider I/WE acknowledge that the School may disclose any
appropriate. information or data regarding our application upon
I/WE hereby give permission for physical evaluation orders of courts or requests of competent government
that may include, but is not limited to, unannounced offices or agencies authorized by law.
site visits of our permanent residence, real estate, and I/WE hereby give permission for the School to request
our childs dormitory, with physical inventory of our information and to make necessary inquiries about me
home and dorm contents and assets. or my family from third parties in connection with our
I/WE also give specific permission to obtain personal application for financial aid.
financial information from the BIR, the LTO, I/WE agree if accepted as a scholar that our
PhilHealth, DOLE, local and international banks, and admission, matriculation, and graduation are subject
any other source of information pertinent to our to the rules and regulations of the Ateneo de Manila
application for financial aid. University.
___________________________________________ _____________________________________
Parent/Guardians Signature over printed name / Date Parents Signature over printed name / Date
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