ASMPH Financial Aid Form for Non-OFW Applicants

Ateneo de Manila University
School of Medicine and Public Health
Financial Aid Application Form NON OFW Income
NEW APPLICATIONS ONLY

THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME
If some or all of your income is from outside the Philippines, please use ASMPH FA APPLICATION - NEW - OFW INCOME 2013-14
SY 2013 2014
INSTRUCTIONS
1. THIS APPLICATION SHOULD BE ACCOMPLISHED BY THE
APPLICANT. ALL QUESTIONS MUST BE ANSWERED
CAREFULLY AND COMPLETELY. FORMS THAT ARE NOT
COMPLETELY FILLED OUT WILL NOT BE PROCESSED.
3. SUBMIT THE FOLLOWING SUPPORTING
DOCUMENTS BEFORE THE INTERVIEW:
A. THIS APPLICATION FORM;
A. CERTIFICATE OF EMPLOYMENT & COMPENSATION

(INCLUDING BONUSES, COMMISSIONS, AND 13TH MONTH
PAY ALLOWANCES) FOR THE CURRENT YEAR FROM
CURRENT EMPLOYER/COMPANY FOR EACH EMPLOYED
B. APPLICANTS DETAILED PERSONAL NEEDS

ESSAY ABOUT THE FAMILYS FINANCIAL SITUATION
B. IF PARENTS ARE SELF-EMPLOYED, PLEASE SUBMIT A
2. SUBMIT THE FOLLOWING BY THE DEADLINE:
WHICH CLEARLY EXPLAINS WHY THERE IS A NEED FOR

FINANCIAL AID. THIS ESSAY MUST BE COMPLETE AND
TRUTHFUL AS TO THE REASONS FOR ASKING FOR FINANCIAL
AID.
C. PHOTOS OF:
i. PERMANENT and LOCAL residences
(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 rented) showing the FRONT and
SIDE of EACH VEHICLE
iii. EACH PROPERTY, LOT, or HOUSE (other than
PERMANENT or LOCAL RESIDENCES)
SHOWING the OUTSIDE (FRONT, BACK,
SIDES) of the HOUSE or PROPERTY as well as
the ROOMS INSIDE THE HOUSE.
DOCUMENTS YOU MUST SUBMIT CHECKLIST:
FINANCIAL AID APPLICATION

PERSONAL NEEDS ESSAY
PHOTOS OF:
RESIDENCES, HOUSES, DORM ROOMS, LOTS,
ETC.
VEHICLES
PARENT AND SIBLING OF THE APPLICANT STILL RESIDING

WITH THE FAMILY;
DETAILED DESCRIPTION OF THE BUSINESS AND AN INCOME
& EXPENSE FINANCIAL STATEMENT FOR THE YEAR;
C. IF PARENTS WERE RETIRED OR RETRENCHED IN THE

PAST THREE YEARS, PLEASE SUBMIT A COPY OF
CERTIFICATION INDICATING AMOUNT OF RETIREMENT OR
SEPARATION BENEFITS, IF RECEIVED.
D. LATEST INCOME TAX RETURN FOR EACH EMPLOYED/SELFEMPLOYED PARENT OF APPLICANT. IF NOT AVAILABLE,
PLEASE EXPLAIN IN YOUR LETTER;
4. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.

5. PLACE YOUR DOCUMENTS IN A SEALED LEGAL SIZE
BROWN ENVELOPE LABELED WITH YOUR NAME
(LAST, FIRST, MI) IN THE UPPER LEFT CORNER AND
SUBMIT THESE DOCUMENTS TO:
CHRISTOPHER K. PEABODY,
ADVANCEMENT OFFICER,
ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH
ASMPH BUILDING, ORTIGAS AVENUE 1604, PASIG CITY
CERTIFICATE OF EMPLOYMENT OR
SELF-EMPLOYED BUSINESS DESCRIPTION &
BALANCE SHEETS OR
RETIREMENT OR RETRENCHMENT INFORMATION
LATEST ITR
LEGAL SIZE BROWN ENVELOPE
Page 1 of 19

SY 2013 - 2014
Financial Aid Application Form NON OFW Income

THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME
If some or all of your income is from outside the Philippines,
ASMPH FA APPLICATION - NEW - OFW INCOME 2013-14
ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED AND ARE GIVEN
EXCLUSIVELY ON THE BASIS OF FINANCIAL NEED FOR A PERIOD OF ONE YEAR.
FINANCIAL AID MEANS A SHARING OF BURDEN. THUS, THE ASMPH EXPECTS
THAT FAMILIES WILL SACRIFICIALLY CARRY AS MUCH OF THE BURDEN OF
THEIR CHILDS EDUCATION AS POSSIBLE.
Recent
2 x 2
Photo of
Applicant
Please PRINT or TYPE. Credentials filed in support of this application become the
property of the Ateneo de Manila University and are NOT returnable to the applicant.
Misrepresentation of Information requested in this application will be considered
sufficient reason for refusal of admission and exclusion.
LEGAL NAME ________________________________________________________________________________

(Name in Birth Certificate)
Last Name
First Name
Middle Name
Nickname _________________________ School ___________________________________________________________

Degree ______________________________________________________________________________________________
1. SCHOLARSHIP REQUEST
GRANT REQUESTED
NEW ONLY
APPLICATION
100TF 75TF
If you are not granted financial aid, will you continue in ASMPH?
50TF 25TF
[ ] Yes
[ ] No
100TF 75TF 50TF 25TF _____

how much did you receive? (check all that apply) Dorm Books Food _________
If you received financial aid in COLLEGE,
2. PERSONAL INFORMATION
Permanent
Address
Mailing Address
(If not the same as the
permanent address)
Street No.
Street No.
Street
Subdivision/Barangay
City/Municipality
Province
Country
ZIP code
Street
City/Municipality
Province
Country
ZIP code
Street
City/Municipality
LOCAL Address
Street No.
You live with/in
ZIP code
[ ] relatives [ ] a boarding house/dorm [ ] house/condo/apartment [ ] other _____________

How many do you share with? ________
Please attach RECENT LABELED PHOTOS OF PERMANENT and LOCAL RESIDENCE

where you stay showing the OUTSIDE (FRONT, BACK, SIDES)
of the HOUSE OR APARTMENT as well as the ROOMS INSIDE.
PLEASE DO NOT WRITE BELOW THIS LINE
ADM RANK_____ SCORE____ FA RANK_____ STAR _____ Schl/ Course _________________ QPI: _____ / _____ out of 4.0
NMAT______ INTV_____
INTV RECMD______ OAA____________ FA REQ___________ FA ECMD_____________________
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2013-14
Page 2 of 19
Applicants
Telephone
Numbers
E-mail Address(s)
Residence
Mobile No. 1
)
)
Area Code
Mobile No. 2
2. ________________________________________________
Age
(MM/DD/YEAR)
If married, name
of spouse
1. ________________________________________________
Date of Birth
Citizenship
Civil Status
Office
Area Code
[ ] Filipino
[ ] Single
Area Code
Area Code
[ ] Male
[ ] Female
Gender
Place of Birth
[ ] Others, pls. specify

[ ] Married
[ ] Separated
[ ] Widowed
PhilHeath
Blood Type
[ ] YES [ ] NO
Mobile No.
Contact No.
Last Name
First Name
Area Code
Middle Name
3. FAMILY INFORMATION
FATHER
PLEASE INDICATE IF:
Is he the Primary Wage earner of Family

Fathers Name
Fathers Address
[ ] SINGLE PARENT
[ ] YES [ ] NO
Last Name
Street No.
Street
Fathers e-mail
Address(s)
Fathers
education
Residence
Mobile No. 1
Middle Name
City/Municipality
Country
ZIP code
Office
Mobile No. 2
Area Code
[ ] SEPARATED
Age (or Deceased)
First Name
Province
Fathers
Telephone
Numbers
[ ] WIDOWED
Area Code
1. ____________________________________
Area Code
Area Code
2. ____________________________________
Highest educational attainment _____________________________________________________

School/course/years attended or graduated ___________________________________________
Year Graduated _________________
Degree _________________________________________
If employed, name of company/employer ____________________________________________

Fathers
employment /
earning capacity
Position in firm ________________________________
Years in firm _________________
Annual gross salary in the firm ___________________

If self-employed, nature of work _____________________________________________________
If your Father is the primary wage earner AND currently UNEMPLOYED,

please attach a separate letter explaining
when last employed and reason for unemployment
MOTHER
PLEASE INDICATE IF:
Is she the Primary Wage earner of Family

Mothers Name
Mothers
Last Name
[ ] SINGLE PARENT
[ ] YES [ ] NO
[ ] WIDOWED
Age (or Deceased)
First Name
Street No.
Street
[ ] SEPARATED
Middle Name
City/Municipality
Country
ZIP code
Address
Province
Mothers
Telephone
Numbers
Residence
Mobile No. 1
Office
Mobile No. 2
Area Code
Area Code
Area Code
Area Code
Page 3 of 19
Mothers e-mail
Address(s)
1. ____________________________________
2. ____________________________________

Mothers
education

Degree _________________________________________

Mothers
employment /
earning capacity
Position in firm ________________________________
Years in firm _________________

If your Mother is the primary wage earner AND currently UNEMPLOYED,

GUARDIAN
RELATIONSHIP TO YOU:
(If applicable)
If he/she responsible for your financial needs :

Guardians
Name
Last Name
Street
Province
Fathers
Telephone
Numbers
Residence
Mobile No. 1
Fathers e-mail
Address(s)
Age
First Name
Street No.
Fathers Address
[ ] YES [ ] NO
Middle Name
City/Municipality
Country
ZIP code
Office
Mobile No. 2
Area Code
Area Code
1. ____________________________________
Area Code
Area Code
2. ____________________________________
Guardians
education

Degree _________________________________________

Guardians
employment /
earning capacity
Position in firm ________________________________
Years in firm _________________

If your Guardian is the primary wage earner AND currently UNEMPLOYED,

Person to Contact in
case of emergency
Emergency
[ ] Father
[ ] Mother
[ ] Guardian
[ ] Spouse
[ ] Other (please specify name) ________________________________________
Street No.
Street
Province
Country
City/Municipality
Contact Address
Emergency Contact
Telephone Numbers
Residence
Mobile No. 1
ZIP code
Office
Mobile No. 2
Area Code
Area Code
Area Code
Area Code
Page 4 of 19
SIBLINGS 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
Do you have any relatives who have attended or are attending Ateneo de Manila?
NAME
Relation
Level/Year&Course
Graduated
4. APPLICANT ACADEMIC INFORMATION

SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)
Elementary School
Levels
Attended
Address
Period Covered
High School
Levels
Attended
Address
Period Covered
College
Yr. _____ To ______

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

19 _____ to 20 ______
20 _____ to 20 ______
Degree
Address
Period Covered
20 _____ to 20 ______
List any HONORS OR PRIZES you have received for academic excellence in HS / College or at special events such as science
nd
contests, writing contests, etc. (indicate honors and year, ex. 2 Honors, Freshman; Honorable Mention, Sophomore; Prize won,
sponsoring group, year). You may use a separate sheet in needed. Attach a separate sheet if needed
Are you graduating with Honors?
[ ] No
[ ] Yes, I graduated/expect to graduate:

[ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention
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
Page 5 of 19
Other work experience after graduation from College - Attach a separate sheet if needed
Position
Company and Address
Date
Were you ever dismissed, suspended or placed on probation? [ ] Yes

[ ] No
If Yes, specify dates, offenses, penalties _____________________________________________________________
6. FAMILY GROSS INCOME (Philippine based only)

please use ASMPH FA APPLICATION - NEW - OFW INCOME 2013-14
Contributed Annual Income given
SAVING & Other Income:
Father
Mother
Brothers
Sisters
Money Market Placements

Market Value of Securities
Bank Deposits
Current
SUB-TOTAL from FAMILY
Savings
For the following, ALSO fill out Section 21
Support from Grandparents

Support from Uncles/Aunts
Support from Other relatives
Support from Friends
Time Deposit
Stocks
Foreign Currency Deposit
Interest earned on all above
Other (specify): ______________________
Other (specify): ____________________

Other (specify): ____________________
Other (specify): ____________________
SUB-TOTAL from RELATIVES/FRIENDS
SUB-TOTAL FOR SAVINGS, ETC
From Relatives/friends overseas
PROFITS EARNED
LOANS FOR LIVING EXPENSES
Profit on Business
Profit/Rentals on Lands
Rentals on Residence/Buildings
Commissions
Retirement Benefits/Pensions
Borrowed from family

Borrowed from Friends
Borrowed from banks or others
Other Loans(specify): _______________
SUB-TOTAL for PROFITS EARNED
SUB-TOTAL for LOANS
Other Income (specify):

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
SUB-TOTAL for OTHER INCOME
TOTAL GROSS ANNUAL INCOME =

Page 6 of 19
7. FAMILY GROSS EXPENSES (Philippine based only)

please use ASMPH FA APPLICATION - NEW - OFW INCOME 2013-14
If the applicant does not live with family, please DO NOT ADD APPLICANT EXPENSES TO
FAMILY EXPENSES BELOW. Instead, please ANSWER DORM SECTION below.
BASIC MONTHLY FAMILY EXPENSES
ACTUALLY PAID
UNPAID or OWED
ACTUALLY PAID
UNPAID or OWED
Food/Grocery
House Rent/Amortization
Electricity
Water
LPG
Telephone (landline)
DSL/ Broadband
Cable TV
Cell phone
Clothing, Uniforms
Transportation (parents)
School Bus or car pool
Salaries of helpers, housekeeper, driver, others
Medicines (if total is greater than P500 per month,
please fill out Section 19)
SUB-TOTAL for BASIC MONTHLY FAMILY EXPENSES
MONTHLY CREDIT EXPENSES

Monthly Loan payments (please identify to whom/why paid)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for MONTHLY LOAN PAYMENTS
Monthly Credit Card payments

____________________________________________
____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for MONTHLY CREDIT CARD PAYMENTS
Other Monthly Payments (please identify to whom/why paid)

____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for OTHER MONTHLY PAYMENTS
BASIC MONTHLY EXPENSES SUBTOTAL

Page 7 of 19
DORM SECTION: IF YOU DO NOT LIVE WITH YOUR FAMILY

(i.e. Dorm, shared apartment, room or coop, etc.),
please ANSWER BELOW:
Rent per month paid by applicant
Electricity/water/gas/condo dues paid by applicant
Food purchased whether in school of at dorm/condo
Transportation costs to & from dorm/condo/hospital/LEC
Transportation costs to & from parents
Xeroxing, etc.
Internet in dorm or broadband
Other personal needs (specify): ____________________________
____________________________________________
____________________________________________
Medical expenses for the applicant (if total is greater than P500
per month, please fill out Section 19)
TOTAL MONTHLY FAMILY EXPENSES
MONTHLY SUB-TOTAL for DORM EXPENSES
(BASIC + DORM)
TOTAL MONTHLY FAMILY EXPENSES X 12 =
TOTAL MONTHLY EXPENSES PER YEAR

8. ANNUAL FAMILY EXPENSES (Philippines based income)
ANNUAL FAMILY EXPENSES
ACTUALLY PAID
UNPAID or OWED
School Tuition & Fees (please give details in # 10 below)

School Supplies/Books (please give details in # 10 below)
Withholding Tax (per year)
Insurance Plans (compute per year)
SSS/GSIS/Pag-Ibig/PhilHealth
Other ANNUAL expenses (specify): ________________________
_________________________
SUB-TOTAL for ANNUAL FAMILY EXPENSES
TOTAL FAMILY EXPENSES =

(MONTHLY X 12) + (ANNUAL)
Page 8 of 19
9. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET (Philippines based income)
UNPAID or
OWED
ACTUALLY PAID
TOTAL GROSS ANNUAL INCOME +
TOTAL ANNUAL EXPENSES/DEBT --
--
SURPLUS/ LOSS FOR THE YEAR

NOTE IF SURPLUS/LOSS FOR THE YEAR IS SIGNIFICANTLY NEGATIVE
(I.E. YOUR FAMILY SPENDS MORE THAN 10% THAN IT EARNS)
YOU ARE REQUIRED TO ATTACH
A SPECIAL LETTER FROM YOUR PARENTS EXPLAINING
HOW THEY ARE ABLE TO PAY THIS.
DO NOT SKIP THIS STEP
10. TUITION & FEES for Siblings CURRENTLY IN SCHOOL or ABOUT TO GO TO SCHOOL
Applicant and
Siblings NAMES
Age
School
Grade/
Year Level
Yearly Tuition
& Fees of
school
Yearly School
Supplies/
Books
Amount
covered by
parents
11. PERSONAL POSSESSIONS DECLARATION

Please list all possessions worth more than P2, 500 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
Approximate
exclusively for you, Acquired
Acquisition
Item
Name/brand/model #
who else uses it
When
Cost
Laptop
PC / Tablet
Printer
External Hard Drive
Page 9 of 19
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
Car (fill out section 19)
Jewelry/watch
(specify):
Braces
Other (specify):
Other (specify):
Other (specify):
12. FAMILY HOUSEHOLD POSSESSIONS DECLARATION

Please list all possessions worth more than P5,000 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
Page 10 of 19
Cellular phones
Laptop
PC
Printer
Refrigerators/ Freezers
Microwave/Oven
Washing Machine/Dryer
Air conditioner
Piano/organ
Other (specify):
Other (specify):
Other (specify):
13. 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
14. 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.
Bank
Type of account
(savings/checking/atm)
Acquired When
Current balance
Page 11 of 19
15. FAMILY BANK ACCOUNTS

Please list ALL YOUR FAMILYS BANK ACCOUNTS that they OWN or USE
Be VERY complete & clear - these details may be subject to verification.
Type of account
(savings/checking/atm)
Bank
Who uses the card
Acquired When
Current balance
16. PERSONAL CREDIT OR DEBIT CARDS

Please list ALL CREDIT or DEBIT CARDS that YOU USE whether you pay for it or not.
Be VERY complete & clear - these details are subject to verification.
Credit or Debit Card
Who Pays the Bill
Acquired When
Current Credit Limit
17. 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 Card
Who uses the card
Who Pays the Bill
Acquired When
Current Credit Limit

Page 12 of 19
18. DOMESTIC OR INTERNATIONAL TRAVEL BY YOU PERSONALLY

OR YOUR IMMEDIATE FAMILY DURING THE PAST 3 YEARS
This includes ALL TRIPS to/from your permanent residence or to/from ASMPH or
your college if greater than 200 km. Leave any item blank if not applicable.
For ASMPH students, please include travel required by your summer internship.
Be VERY complete & clear - these details are subject to verification
Person(s) traveling &

relationship to you:
Purpose of trip
(i.e. vacation,
emergency, etc.)
Dates of
trip
By Ship
Airline,
Bus,
or Car
Destination(s)
Estimated
Cost of trip
Who paid
for the
trip?
19. 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

Page 13 of 19
20. FAMILY PPROPERTIES 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
21. SIBLINGS NO LONGER IN SCHOOL
Name
Age
Civil
Status
Still
residing
with
you?
Highest
educational
attainment &
school attended
Position
Where employed
in the
(Company & Location)* Firm**
*If unemployed, state reason.
Annual
Gross
Income**
**Do not leave blank.
22. SERIOUS ACUTE OR CHRONIC ILLNESSES

IF YOUR MONTHLY MEDICAL OR MEDICINE BILLS ARE GREATER THAN P500 PER MONTH, please detail those serious
Age
Diagnosis
# of times
hospitalized
Name
Relationship
to you
medical, surgical, physical or mental disabilities, or mental illnesses which cause your family to spend.
Current
treatment
/medicines
required
Est. annual
treatment
cost
ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENT
Page 14 of 19
23. OTHER DEPENDENTS LIVING IN YOUR HOUSE
Name
Relation- Reason for

Civil ship to staying with
Age Status
you
family
Where employed
(Company &
Location)*
*If unemployed, state reason.
Annual
Position in Gross
the Firm** Income**
**Do not leave blank.
24. RELATIVES, FRIENDS, ETC. WHO HELP WITH HOUSEHOLD & EDUCATIONAL EXPENSES
Indicate duration and extent of financial support (for whom, how much per month/year).
Name
Who
Relation- receives
ship to you
help
Help for
what
When did
they start How much Total
helping per month per year
If they will not

continue, why
25. SIBLINGS ON ATENEO SCHOLARSHIPS & EDUCATIONAL PLANS

Yes
Are any of your siblings presently on scholarship in Ateneo:

Please check if any of your siblings
presently on scholarship in Ateneo:
No
Merit/Athletic Who/how much? ________________________________

Financial aid Who/how much? __________________________________
In which school(s):
Grade School
Please list siblings and type of scholarship of who received

scholarships in the past from the Ateneo de Manila?
Do not list yourself.
Are any of your siblings enrolled under an
education plan for:
What company?
High School
Loyola Schools
______________________________________
______________________________________
______________________________________
Grade School High School

Loyola Schools
____________________________________________
26. WORKING STUDENT DECLARATION

If you are a working student, how many hours do you work:
What days of the week?
If working regularly interferes with your
studying,
what do you plan to do?
Per day?
Per week?
_______________________________________________
________________________________________________
________________________________________________
Page 15 of 19
27. EMIGRATION & OFW DECLARATION

Are any of your immediate family members under petition for immigration or
have any pending visa application to another country
If so, please indicate the names of those who are
leaving and give brief details.
No
__________________________________________________
__________________________________________________
Does anyone in your immediate family have plans to leave

the country for employment within the next year?
If so, please indicate the names of those who are
leaving and give brief details.
Yes
Yes
No
__________________________________________________
__________________________________________________
28. YOUR EXPERIENCE WITH MEDICINE

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

hospitalized children or adults?
Yes
No
Have you ever joined a medical mission or helped during any medical procedures?
Yes
No
Have you visited any medical schools prior to applying to ASMPH?
Yes
No
Have you ever been confined as 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

your doctor or teacher?
Yes
No
Have you ever spent time with a doctor relative while they practice medicine?
Yes
No
Have you ever spent time with a doctor or

other health professional as they do their job?
Yes
No
Have you ever worked in a hospital or health center as volunteer?
Yes
No
On a scale from 1 to 5, please rate

HOW HAPPY YOU ARE ABOUT THE FOLLOWING:
Unhappy
Very Happy
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
3 year mandatory service requirement for ASMPH scholars
ASMPH Scholar requirement to find support for a new ASMPH

scholar within 20 years after ASMPH graduation
Page 16 of 19
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:
Your boyfriend/girlfriend?
Won't give up
Willing to give up
Your weekends?
Won't give up
Willing to give up
Your co-curriculars or orgs or

non-worship church activities?
Won't give up
Willing to give up
going to movies
Won't give up
Willing to give up
going to gimmicks or parties
Won't give up
Willing to give up
reading non medical literature
Won't give up
Willing to give up
watching TV or DVDs
Won't give up
Willing to give up
Seeing your family as often?
Won't give up
Willing to give up
On a scale from 1 to 5, please rate the following:

How much do your parents
want you to go to medical school?
Against my
going
TOTALLY
determined
How important is it to your parents

that you become a doctor?
How much did your parents Influence you
to become a doctor?
Not
important
Very
important
No
influence
Highly
influenced
How much did your classmates or course

influence you to become a doctor?
No
influence
Highly
influenced
How often you have doubts

about going to medical school?
No doubts
Frequent
doubtful
How would you rate your commitment

to finishing medical school?
Unsure if I'll
finish)
Totally
committed
How much you REALLY

want to go to medical school?
Will go if
accepted
totally
determined
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 after graduation or residency?
Yes
No
Page 17 of 19
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?
29. 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.
30. PERSONAL NEEDS ESSAY
In order for the Committee on Admission and Aid to understand your needs, write
an essay about yourself and your family explaining why you need financial aid. You
must be honest and complete. All information you give is confidential and will not
be shared with anyone without your written permission.
(Guidelines: 2-3 pages short bond paper, single-spaced, Times New Roman font, and 12 pt.)
31. Persons to Recommend You
Please name two persons in your community (excluding relatives) whom the Committee
may get in touch with for possible inquiry. (Do not leave this blank
Name
Address
Contact Numbers
_____________________________________________________________________________
_____________________________________________________________________________
Page 18 of 19

Financial Aid Application Form

I hereby certify that all information written in this application is complete and accurate and we
are hereby authorized to verify the same.
I understand that misrepresentation of information or withholding of information requested in
this questionnaire will be considered reason for disapproval or cancellation of 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.
________________________________________________________
Applicants Signature
Date
________________________________________________________
Parents or Guardians Signature
Date
Do not write below this line.
Page 19 of 19

ASMPH Financial Aid Form for Non-OFW Applicants

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ASMPH Financial Aid Form for Non-OFW Applicants

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Ateneo de Manila University

School of Medicine and Public Health

Financial Aid Application Form NON OFW Income

NEW APPLICATIONS ONLY

3. SUBMIT THE FOLLOWING SUPPORTING

DOCUMENTS BEFORE THE INTERVIEW:

A. THIS APPLICATION FORM;

A. CERTIFICATE OF EMPLOYMENT & COMPENSATION

B. APPLICANTS DETAILED PERSONAL NEEDS

B. IF PARENTS ARE SELF-EMPLOYED, PLEASE SUBMIT A

2. SUBMIT THE FOLLOWING BY THE DEADLINE:

WHICH CLEARLY EXPLAINS WHY THERE IS A NEED FOR

DOCUMENTS YOU MUST SUBMIT CHECKLIST:

FINANCIAL AID APPLICATION

PARENT AND SIBLING OF THE APPLICANT STILL RESIDING

C. IF PARENTS WERE RETIRED OR RETRENCHED IN THE

4. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.

Ateneo de Manila University

Financial Aid Application Form NON OFW Income

LEGAL NAME ________________________________________________________________________________

Nickname _________________________ School ___________________________________________________________

100TF 75TF 50TF 25TF _____

You live with/in

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

Please attach RECENT LABELED PHOTOS OF PERMANENT and LOCAL RESIDENCE

ASMPH Financial Aid APPLICATION - NON OFW INCOME 2013-14

[ ] Others, pls. specify

PLEASE INDICATE IF:

Is he the Primary Wage earner of Family

Age (or Deceased)

Highest educational attainment _____________________________________________________

If employed, name of company/employer ____________________________________________

Position in firm ________________________________

Years in firm _________________

Annual gross salary in the firm ___________________

If your Father is the primary wage earner AND currently UNEMPLOYED,

PLEASE INDICATE IF:

Is she the Primary Wage earner of Family

Age (or Deceased)

ASMPH Financial Aid APPLICATION - NON OFW INCOME 2013-14

Highest educational attainment _____________________________________________________

School/course/years attended or graduated ___________________________________________

If employed, name of company/employer ____________________________________________

Position in firm ________________________________

Years in firm _________________

Annual gross salary in the firm ___________________

If your Mother is the primary wage earner AND currently UNEMPLOYED,

If he/she responsible for your financial needs :

Highest educational attainment _____________________________________________________

School/course/years attended or graduated ___________________________________________

If employed, name of company/employer ____________________________________________

Position in firm ________________________________

Years in firm _________________

Annual gross salary in the firm ___________________

If your Guardian is the primary wage earner AND currently UNEMPLOYED,

ASMPH Financial Aid APPLICATION - NON OFW INCOME 2013-14

SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a separate sheet if needed

School last attended

Attach a separate sheet if needed

Attach a separate sheet if needed

4. APPLICANT ACADEMIC INFORMATION

Yr. _____ To ______

Gr. _____ To ______

Nickname _ School ___________________________________

Yr. _ To __

Gr. _ To __