ATENEO SCHOOL OF MEDICINE & PUBLIC HEALTH

Financial Aid Application Form

Financial Aid Application Form – SY 20__ - 20__
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
Page 1 of 45
 showing the OUTSIDE (FRONT,
BACK, SIDES) of the HOUSE or
apartment as well as the ROOMS
INSIDE.
ii. EACH VEHICLE (whether
owned, borrowed, loaned, or
rented) showing the FRONT and
SIDE of EACH 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 WITH THIS
APPLICATION FORM:
a. Certificate of Employment &
Compensation for currently
employed parents, siblings 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;
If parents are self-employed, please submit
a detailed description of the
b. 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;
e.Copies of the following:
i. Electricity bill
ii. Water bill
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 Scholarship Committee
c/o Admissions Office, ASMPH,
Ortigas Ave. 1604, Pasig City
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 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 Last name, first, MI

□ BIR I.T.R. FOR 2016

□ Legal size brown envelope
TO: ASMPH Scholarship Committee
□ Applicant’s Name in TOP LEFT corner as
Registrar’s Office, ASMPH ,
“Last name, first name, MI”
Ortigas Ave. 1604, Pasig City

Page 3 of 45
 ATENEO SCHOOL OF MEDICINE & PUBLIC HEALTH
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.

LEGAL NAME ________________________________________________________________________________

(Name in Birth Certificate) Last Name First Name Middle Name

Nickname ____________________ School ________________________________________________________

Degree _______________________________________________________Date of graduation ______________

Cumulative where highest grade is equivalent

4 5 1
QPI/GPA to

NMAT % taken when Part I % Part I %

Inductive Perceptual
Verbal Quantitative
Reasoning Acuity
Biology Physics Social Science Chemistry

₅₆Are you graduating with [ ] No [ ] Yes, I graduated/expect to graduate:

HONORS? [ ] Summa Cum Laude [ ] Magna Cum Laude
[ ] Cum Laude [ ] Honorable Mention

Page 4 of 45
 1. SCHOLARSHIP REQUEST
₂ PERCENTAGE GRANT
100% TF 75% TF 50% TF 25% TF
REQUESTED
₃ If you are NOT granted financial aid, will you continue in ASMPH? [ ] Yes [ ] No
₄If 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

₇Permanent Street No. Street Subdivision/Barangay City/Municipality

Address

Province Country ZIP code

₈Mailing Address
(If not the same Street No. Street Subdivision/Barangay City/Municipality
as permanent
add.)
Province Country ZIP code
₉LOCAL Address
where you stay
during school Street No. Street Subdivision/Barangay City/Municipality ZIP code

[ ] relatives [ ] a boarding house/dorm [ ] house/condo/apartment

₁₀You live with/in
[ ] other ___________________ How many do you share with? ________

₁₁Applicant’s Residence ( ) Office ( )

Area Code Area Code
phone
Numbers Mobile No. 1 ( ) Mobile No. 2 ( )
Area Code Area Code

1. ________________________________________________
₁₂E-mail [ ] Male
₁₃Gender
Address(s) 2. ________________________________________________ [ ] Female

₁₄Date of Birth
₁₅Age ₁₆Place of Birth
(MM/DD/YEAR)
₁₇Citizenship [ ] Filipino [ ] Others, pls. specify [ ] YES
₁₈PhilHealth
[ ] NO
₁₉Civil Status [ ] Single [ ] Married [ ] Separated [ ] Widowed ₂₀Blood Type
₂₁If married,
name of Age
spouse Last Name First Name Middle Name
Mobile No. Address
Contact No. ( ) if different
Area Code

Page 5 of 45
 3. FAMILY INFORMATION
FATHER ₂₂PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED
23Is he the Primary Wage earner of Family [ ] YES [ ] NO 24Age

₂₅Father’s Name
Last Name First Name Middle Name

₂₆Father’s Street No. Street Subdivision/Barangay City/Municipality

Address
Province Country ZIP code

₂₇Father’s Residence ( ) Office ( )

Area Code Area Code
Telephone
Mobile ( ) Mobile ( )
Numbers
No. 1 Area Code No. 2 Area Code
₂₈Father’s e-mail
1. ____________________________________ 2. ____________________________________
Address(s)
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 /
earning capacity [ ] Regular or [ ] Contractual Annual gross salary in the firm ___________________
If self-employed, nature of work ______________________________________________
Do you [ ] own or [ ] share ownership of this business?
If Father is primary wage earner AND currently UNEMPLOYED, please attach a separate
letter explaining when last employed and reason for unemployment

MOTHER ₃₁PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED

₃₂Is she the Primary Wage earner of Family [ ] YES [ ] NO ₃₃Age
₃₄Mother’s
Name Last Name First Name Middle Name

₃₅Mother’s Street No. Street subdivision/Barangay City/Municipality

Address
Province Country ZIP code
Page 6 of 45
 ₃₆Mother’s Residence ( ) Office ( )
Area Code Area Code
Telephone
Mobile ( ) Mobile ( )
Numbers
No. 1 Area Code No. 2 Area Code
₃₇Mother’s e-
1. ____________________________________ 2. ____________________________________
mail Address(s)
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 /
earning capacity [ ] Regular or [ ] Contractual Annual gross salary in the firm ___________________
If self-employed, nature of work ______________________________________________
Do you [ ] own or [ ] share ownership of this business?
If Mother is primary wage earner AND currently UNEMPLOYED, please attach a separate
letter explaining when last employed and reason for unemployment
GUARDIAN (If applicable) ₄₀RELATIONSHIP TO YOU:

₄₁ Is he/she responsible for your financial needs : [ ] YES [ ] NO ₄₂Age

₄₃Guardian’s
Name Last Name First Name Middle Name

₃₅Guardian’s Street No. Street Subdivision/Barangay City/Municipality

Address
Province Country ZIP code

₃₆Guardian’s Residence ( ) Office ( )

Area Code Area Code
Telephone
Numbers Mobile Mobile
No. 1
( ) No. 2
( )
Area Code Area Code

₃₇Guardian’s
1. ____________________________________ 2. ____________________________________
e-mail Address(s)
Highest educational attainment ______________________________________________
₄₇Guardian’s School/course/years attended or graduated ____________________________________
education Year Graduated __________ Degree _________________________________________
PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no

₄₈Guardian’s If employed, name of company/employer ______________________________________

employment / Location of employer_______________________________________________________
earning capacity
Position in firm ________________________________ Years in firm ______________

Page 7 of 45
 [ ] Regular or [ ] Contractual Annual gross salary in the firm ___________________
If self-employed, nature of work ______________________________________________
Do you [ ] own or [ ] share ownership of this business?

If Guardian is primary wage earner AND currently UNEMPLOYED, please attach a

separate letter explaining when last employed and reason for unemployment

₄₉Person to Contact [ ] Father [ ] Mother [ ] Guardian [ ] Spouse

in case of [ ] Other (please specify name) ________________________________________
emergency

₅₀Emergency Street No. Street Subdivision/Barangay City/Municipality

Contact Address
Province Country ZIP code
Reside ( )
Office
( )
₅₁Emergency Area Code Area Code
nce
Contact Telephone
Numbers Mobile ( )
Mobile No. 2
( )
No. 1 Area Code Area Code

₅₂SIBLING’S EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a separate sheet if needed

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)
Elementary Levels
School Attended Gr. _____ To ______
Address Period Covered 19 _____ to 20 ______
High School Levels
Attended Yr. _____ To ______
Address Period Covered 20 _____ to 20 ______
College
Degree

Address Period Covered 20 _____ to 20 ______

Post Graduate
Degree
(Including other
College of Medicine)
Address Period Covered 20 _____ to 20 ______

Page 8 of 45
 ₅₅List 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

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
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

INCOME PROJECTED
6A. FAMILY INCOME ACTUALLY INCOME INCOME
If PARENT OR SIBLING SENDS MONEY from RECEIVED UNPAID or (CURRENT
OVERSEAS, below LIST ONLY THE MONEY SENT (LAST YEAR) OWED YEAR)
Father
Mother
Brothers
Sisters
6A. FAMILY INCOME SUB-TOTAL
Page 9 of 45
 INCOME PROJECTED
6B. OTHER SUPPORT from ACTUALLY INCOME INCOME
RELATIVES & FRIENDS RECEIVED UNPAID or (CURRENT
For the following, ALSO fill out Section 27 (LAST YEAR) OWED YEAR)
Grandparents
Uncles
Aunts
Other relatives
Friends
Other
6B. RELATIVES & FRIENDS SUB-TOTAL
Attach a separate sheet if neede

6C. PROFITS EARNED IN RP INCOME PROJECTED

ACTUALLY INCOME INCOME
RECEIVED UNPAID or (CURRENT
(LAST YEAR) OWED YEAR)
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

Page 10 of 45
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 INCOME PROJECTED

ACTUALLY INCOME INCOME
(specify):
RECEIVED UNPAID or (CURRENT
(LAST YEAR) OWED YEAR)
__________________________________
__________________________________
6E. OTHER INCOME Sub-total
Attach a separate sheet if needed

Page 11 of 45
 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
INCOME PROJECTED
ACTUALLY INCOME
Name of employer, relative, friends, RECEIVED UNPAID or (CURRENT
scholarship or donor who helps you (LAST YEAR) OWED YEAR)

7. Total APPLICANT INCOME for Last Year

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 still PROJECTED
Total 2Amount UNPAID or LOANS
LENDER Borrowed OWED (LAST YEAR)
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
___________________________________

Page 12 of 45
 Bank 3
___________________________________
Borrowed using CREDIT CARDS (specify each)
Card 1
___________________________________
Card 2
___________________________________
Card 3
___________________________________
8. Total LOANS FOR LIVING for Last Year
Attach a separate sheet if needed

9. TOTAL GROSS ANNUAL INCOME SUMMARY

PLEASE COPY THE TOTALS INCOME PROJECTED
ACTUALLY INCOME INCOME
FROM ABOVE RECEIVED UNPAID or (CURRENT
(LAST YEAR) OWED YEAR)
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 ❶ ❶ ❶

INCOME ❶ =

Page 13 of 45
 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:
GROSS PROJECTED
FOREIGN INCOME
INCOME UNPAID or (CURRENT
(LAST YEAR) OWED YEAR)
Father
Mother
Brothers
Sisters
Other
Other
Attach a separate sheet if needed

11. TOTAL MONTHLY FAMILY EXPENSES (In Philippines only)

If the applicant DOES NOT LIVE WITH THE FAMILY DURING SCHOOL YEAR,
DO NOT ADD APPLICANT DORM EXPENSES TO FAMILY EXPENSES BELOW
Instead, please ANSWER DORM SECTION below.
EXPENSES EXPENSES PROJECTED
11A. BASIC MONTHLY FAMILY ACTUALLY UNPAID or COSTS
EXPENSES PAID OWED (CURRENT
(LAST YEAR) (LAST YEAR) YEAR)
Food
Grocery
House Rent
Electricity
Water
LPG
Telephone (landline)
DSL/ Broadband
Cable TV
Page 14 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
Photocopying, etc. BY APPLICANT
______________________________________
11A. Sub-total for BASIC MONTHLY
FAMILY EXPENSES
Attach a separate sheet if needed

11B. MONTHLY LOAN PAYMENTS (banks, SSS, PagIbig, family, friends etc)
PROJECTED
ACTUALLY UNPAID or
(please identify to whom/why paid and if COSTS
PAID OWED
loan is for business) (CURRENT
(LAST YEAR) (LAST YEAR)
YEAR)
Mortgage Amortization
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________

Page 15 of 45
 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
PROJECTED
AVERAGE AVERAGE MONTHLY
(please identify CARD) MONTHLY MONTHLY COSTS
PAID UNPAID BALANCE (CURRENT
YEAR)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11C.Sub-total for MONTHLY
credit card payments
Attach a separate sheet if needed

PROJECTED
ACTUALLY UNPAID or
11D. Other Monthly Payments PAID OWED
COSTS
(please identify to whom/why paid) (CURRENT
(LAST YEAR) (LAST YEAR)
YEAR)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
11D. Sub-total other monthly payments
Attach a separate sheet if needed

❷ ❷ ❷
Page 16 of 45
 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?
PROJECTED
AVERAGE AVERAGE COSTS
MONTHLY MONTHLY UNPAID
(CURRENT
ACTUALLY PAID or OWED
YEAR)
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
____________________________________________
____________________________________________
❸ ❸ ❸
11E. Sub-total for DORM EXPENSES
Attach a separate sheet if needed

11. TOTAL MONTHLY FAMILY ❹ ❹ ❹

EXPENSES (11A+11B+11C+11D+ 11E)
(Basic❷+ Dorm❸)

Page 17 of 45
TOTAL of MONTHLY FAMILY EXPENSES for 1 year
❺ ❺ ❺
MONTHLY❹X 12 MONTHS = ❺

12. TOTAL ANNUAL FAMILY EXPENSES (In Philippines only)

PROJECTED
12A. TUITION PAID 2016 ACTUALLY UNPAID or
COSTS
Please list names of who is receiving tuition help PAID OWED
(CURRENT
(LAST YEAR) (LAST YEAR)
YEAR)
1 APPLICANT
2
3
4
5
6
7
8
Attach a separate sheet if needed

PROJECTED
12B. ANNUAL NON-TUITION ACTUALLY UNPAID or
COSTS
PAID OWED
EXPENSES (LAST YEAR) (LAST YEAR)
(CURRENT
YEAR)
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 18 of 45
 12. Sub-total for ANNUAL ❻ ❻ ❻
family EXPENSES (12A+12B)
Total ANNUAL Expenses ❼ ❼ ❼
(monthly x 12❺) + (Annual❻) =❼

Summary of Total FAMILY LOAN / CREDIT Expenses

PROJECTED
ACTUALLY UNPAID or
COSTS
PAID OWED
(CURRENT
(LAST YEAR) (LAST YEAR)
YEAR)
YEARLY LOAN EXPENSES
YEARLY CREDIT CARD EXPENSES
TOTAL DEBT

13. ANNUAL FAMILY INCOME & EXPENSES

BALANCE SHEET
PROJECTED
ACTUALLY UNPAID or
Please copy your totals and COSTS
PAID OWED
enter them below: (CURRENT
(LAST YEAR) (LAST YEAR)
YEAR)
TOTAL GROSS ANNUAL INCOME ❶ + + +
from page 11 above
TOTAL ANNUAL EXPENSES ❼ -- -- --
from bottom of page 15 above
SURPLUS/ LOSS FOR THE YEAR ❽
Page 19 of 45
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 20 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
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
Washing Machine/
Dryer
Air conditioner

Page 21 of 45
Piano/organ
Braces
Car (fill out section
19)
Jewelry/watch
(specify):
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed

15. FAMILY HOUSEHOLD POSSESSIONS 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

Page 22 of 45
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed

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 (Peso and Foreign Currency) 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 (Peso and Foreign Currency) that
they OWN or USE
Be VERY complete & clear - these details may be subject to verification.
Type of account Who uses Acquired Current
Bank (savings/checking/atm) the card When balance

Page 23 of 45
 Attach a separate sheet if needed

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

Page 24 of 45
 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
Purpose By Ship Estimate Who
Person(s) traveling
(vacation, Dates of Airline, d paid for
& relationship to Destination(s)
emergency, trip Bus, Cost of the
you:
etc.) or Car trip trip?

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
Company/
Make/Yr Model When Purchased Amt of Purchase Amt Paid For Family Owned

Page 25 of 45
 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.
Descriptio
n and/or Acquire Value at Present Yearly Net
use Location Size d When Acquisition Market Value Income

Attach a separate sheet if needed

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.

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, physical or mental disabilities, or mental
illnesses which cause your family to spend.

Page 26 of 45
 Rel # of Current Est.
atio times treatment annual
n to hospit
/medicines treatme
you alized
Name Age Diagnosis 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

Reason for Where employed Position Annual
Civil Relation staying with (Company & in the Gross
Name Age Status to you family Location)* Firm** Income**

Attach a separate sheet if needed *If unemployed, state reason. **Do not leave blank.

27. Relatives, Friends, Etc. Who Help

With Household & Educational Expenses
Indicate duration and extent of financial support (for whom, how much per month/year).
Who When did How Total
Relation to receives Help for they start much per per If they will not
Name you help what helping month year 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 : Yes No
Page 27 of 45
 Merit/ Athletic/
Sibling School Financial aid How much is granted?

Are YOU or any of your siblings enrolled under an education plan in any school : Yes No
Sibling School Company How much?

Attach a separate sheet if needed

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
the country for employment within the next year? Yes No

If so, please indicate the names of those who __________________________________________________

are leaving and give brief details. __________________________________________________

30. Working Student 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?

31. Your Experience with Medicine

Please answer the following questions as truthfully as possible:

Are you a member of the pre-med organization? ❑ Yes ❑ No

Are you a member of any organization which serves poor, sick, or
❑ Yes ❑ No
hospitalized children or adults?
Have you ever joined a medical mission or
❑ Yes ❑ No
helped during any medical procedures?

Page 28 of 45
 Have you visited any medical schools prior to applying to ASMPH? ❑ Yes ❑ No
Have you ever been a patient in a hospital? ❑ Yes ❑ No
Are any of your relatives actively working as doctors? ❑ Yes ❑ No
Have you discussed the life of doctor with a doctor relative or
❑ Yes ❑ No
your doctor or teacher?
Have you ever spent time with a doctor relative
❑ Yes ❑ No
while they practice medicine?
Have you ever spent time with a doctor or
❑ Yes ❑ No
other health professional as they do their job?
Have you ever worked in a hospital or health center as volunteer? ❑ Yes ❑ No

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
Page 29 of 45
 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 Willing to
give up 2 3 4 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:

TOTALLY
How much do your parents Against
1 2 3 4 5 determine
WANT you to go to medical school? my going
d
How IMPORTANT is it to your parents Not Very
1 2 3 4 5
that you become a doctor? important important

How much did your PARENTS No Highly

1 2 3 4 5
Influence you to become a doctor? influence influenced
How much did your CLASSMATES or
No Highly
COURSE influence you 1 2 3 4 5
influence influenced
to become a doctor?
How OFTEN do you have DOUBTS No Frequent
1 2 3 4 5
about going to medical school? doubts doubtful

How STRONG is your COMMITMENT Unsure if Totally

1 2 3 4 5
to FINISHING medical school? I'll finish) committed

Page 30 of 45
 totally
How much you REALLY Will go if
1 2 3 4 5 determine
want to go to medical school? accepted
d

How long have you wanted to become a doctor? Please explain briefly below:

Do you plan to have a family? ❑ Yes ❑ No

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

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?

Page 31 of 45
 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
_____________________________________________________________________________
_____________________________________________________________________________

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.)

Page 32 of 45
Type your ESSAY here:

Page 33 of 45
Page 34 of 45
35. SOFT OR HARD COPIES OF PICTURES OF
CARS, HOMES, DORM, ETC (label each clearly)
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Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

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Pix label = Pix label =
Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

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Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

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Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

Pix label = Pix label =

Paste soft copies of picture here Paste soft copies of picture here

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Pix label = Pix label =

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Pix label = Pix label =

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Paste soft copies of picture here Paste soft copies of picture here

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Page 41 of 45
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

Page 42 of 45
Page 43 of 45
 APPLICANT’S FINANCIAL AUTHORIZATION FORM 20__ – 20__

APPLICANT NAME __________________________________________________________________________

(Name in Birth Certificate) Last Name First Name Middle Name

I, _____________________________________, I consent to the use and disclosure by the Ateneo of

hereby certify that all information written in this information in and relating to my application, to any
application or submitted in support of this of its subsidiaries and affiliates, agents, banks and
application is complete and accurate. banking associations, credit card companies and
associations, financial institutions, credit information
I understand that during the period of any grant
bureaus and their equivalent, third-party service
given, misrepresentation of information or
providers rendering services to the Ateneo, as well as
withholding of information requested for my
third parties authorized by the ASMPH to receive
application will be considered reason for
such information, wherever situated, for confidential
disapproval or cancellation of financial aid and,
use in connection with the exercise of its functions to
where appropriate, grounds for legal action, as
provide financial aid (including but not limited to
well as referral to the Dean for charges of
credit investigation and collection, information
Academic Dishonesty with the potential of
technology systems and processes, data processing,
Dishonorable Dismissal with mandatory
imaging and storage, back-up and recovery and risk
repayment of all grant monies paid.
analyses purposes).
I hereby authorize the Ateneo School of Medicine
I agree that such disclosure or exchange of
and Public Health (ASMPH) to confirm through
information shall not be the basis of any claim against
investigation any information provided by me for
the School or the parties to whom the School makes
my application for ASMPH financial aid from
the disclosure.
whatever sources the school may consider
appropriate. I acknowledge that the School may disclose any
information or data regarding my application upon
I hereby give permission for physical evaluation that
orders of courts or requests of competent government
may include, but is not limited to, unannounced site
offices or agencies authorized by law.
visits of my family's permanent residence, real estate,
and my dormitory, with physical inventory of our I hereby give permission for the School to request
home and my dorm contents and assets. information and to make necessary inquiries about me
and my family from third parties in connection with
I also give specific permission to obtain personal
my application for financial aid.
financial information from the BIR, the LTO,
PhilHealth, DOLE, local and international banks, and I agree if accepted as a scholar that my admission,
any other source of information pertinent to my matriculation, and graduation are subject to the rules
application for financial aid. and regulations of the Ateneo de Manila University

Applicant’s Signature over printed name Date

Page 44 of 45
 PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 20_ – 20____
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.
___________________________________________
Parent/Guardian’s Signature over printed name / Date
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
application for financial aid.
I/WE agree if accepted as a scholar that our
admission, matriculation, and graduation are subject
to the rules and regulations of the Ateneo de Manila
University.
_____________________________________
Parent’s Signature over printed name / Date
Page 45 of 45