FA APPLICATION... · Web viewSSS/GSIS/Pag-Ibig PhilHealth (PARENTS & SIBLINGS) PhilHealth...

Ateneo de Manila University School of Medicine and Public Health

Financial Aid Application Form Financial Aid Application Form – SY 2015 - 2016

THIS FORM IS ONLY FOR NEW APPLICANTS

ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED

FOR ONLY ONE YEAR, RENEWABLE ANNUALLY.

ANY FINANCIAL AID GRANT =TUITION & FEES COST – FAMILY CONTRIBUTION.

ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE BURDEN AS POSSIBLE.

INSTRUCTIONS1. 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/

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CONDOS/ FARMS / etc (whether owned, borrowed, loaned, or rented) where you stay showing the OUTSIDE (FRONT, BACK, SIDES) of the HOUSE or apartment as well as the ROOMS INSIDE.

ii. EACH VEHICLE (whether owned, borrowed, loaned, or rented) showing the FRONT and SIDE of EACH VEHICLE

iii. EACH PROPERTY, LOT, or HOUSE (other than PERMANENT or LOCAL RESIDENCES) (whether owned, borrowed, loaned, or rented) SHOWING the OUTSIDE (front, back, sides) of the HOUSE or PROPERTY as well as the ROOMS inside the house.

3.To be submitted BEFORE or AT THE INTERVIEW:

a. Certificate of Employment & Compensation for currently employed parents, sibilings or applicants (including bonuses, commissions, and 13th month pay allowances)

for the current year from current employer/company for each employed parent and sibling of the applicant still residing with the family;

b. If parents are self-employed, please submit a detailed description of the

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business and an income & expense financial statement for the year;

c. If parents were retired or RETRENCHED IN the past three years, please submit a copy of certification indicating amount of retirement or separation benefits, if received.

d. Latest income tax return for each employed/self-employed parent of applicant. If not available, please

explain in your PERSONAL ESSAY;

4. All information will be kept STRICTLY confidential.

5. Place your documents in a SEALED LEGAL SIZE BROWN ENVELOPE LABELED with YOUR NAME (LAST, FIRST, MI) IN THE UPPER LEFT CORNER

Submit these documents to: ASMPH Financial Aid Committee Registrar’s Office, ASMPH, Ortigas Ave. 1604, Pasig City

DOCUMENTS CHECKLIST: THIS Financial Aid Application WITH Personal Needs Essay written by the Applicant AND Photos of: Residences, houses, dorm rooms, lots, etc Vehicles Parents and/or Applicant’s Certificate of employment OR Parents and/or

Applicant’s Self-employed Business description & balance sheets or Retirement or retrenchment information

BIR I.T.R. FOR 2014 Legal size brown envelope

Applicant’s Name in TOP LEFT corner as “Last name, first name, MI”

Ateneo de Manila University School of Medicine and Public Health

Financial Aid Application Form – SY 2015 - 2016THIS FORM IS ONLY FOR NEW APPLICANTS

PLEASE TYPE / COPYPASTE, PRINT & SUBMIT IN HARD COPY – Do Not EMAIL

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Last name, first, MI

TO: ASMPH Financial Aid Committee

Registrar’s Office, ASMPH ,

Please PASTE a SOFT or HARD copy of

Recent 2” x 2” Photo of The Applicant

ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED FOR ONLY ONE YEAR, RENEWABLE ANNUALLY. ANY FINANCIAL AID GRANT = TUITION & FEES COST – FAMILY CONTRIBUTION. ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE BURDEN AS POSSIBLE.

Please PRINT or TYPE. Credentials filed in support of this application become the property of the Ateneo de Manila University and are NOT returnable to the applicant. Misrepresentation of Information requested in this application will be considered sufficient reason for refusal of admission and exclusion.

LEGAL NAME ________________________________________________________________________________(Name in Birth Certificate) Last Name First Name Middle Name

Nickname ____________________ School ________________________________________________________

Degree _______________________________________________________Date of graduation ______________

Cumulative QPI/GPA where highest grade is equivalent to 4 5 1

NMAT % taken when Part I % Part I %Verbal Inductive

Reasoning Quantitative Perceptual Acuity

Biology Physics Social Science Chemistry

₅₆Are you graduating with HONORS?

[ ] No [ ] Yes, I graduated/expect to graduate: [ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention

1. SCHOLARSHIP REQUEST₂ PERCENTAGE GRANT

REQUESTED100% TF 90% TF 80% TF 70% TF 60% TF 50% TF 40% TF 30% TF 20% TF 10% TF

₃ If you are NOT granted financial aid, will you continue in ASMPH? [ ] Yes [ ] No

₄If you received financial aid in COLLEGE, how much did you receive? (check all that apply)

100TF 75TF 50TF 25TF _____Dorm Books Food _________

2. PERSONAL INFORMATION

₇Permanent Address

Street No. Street Subdivision/Barangay City/Municipality

Province Country ZIP code

₈Mailing Address(If not the same as

permanent add.)



₉LOCAL Address where you stay

during school Street No. Street Subdivision/Barangay City/Municipality ZIP code

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Please PASTE a SOFT or HARD copy of

Recent 2” x 2” Photo of The Applicant

₁₀You live with/in [ ] relatives [ ] a boarding house/dorm [ ] house/condo/apartment [ ] other ___________________ How many do you share with? ________

₁₁Applicant’s phone

Numbers

Residence ( )Area Code

Office ( )Area Code

Mobile No. 1 ( )Area Code

Mobile No. 2 ( )Area Code

₁₂E-mail Address(s)

1. ________________________________________________

2. ________________________________________________₁₃Gender [ ] Male

[ ] Female

₁₄Date of Birth(MM/DD/YEAR) ₁₅Age ₁₆Place of Birth

₁₇Citizenship [ ] Filipino [ ] Others, pls. specify ₁₈PhilHealth [ ] YES [ ] NO

₁₉Civil Status [ ] Single [ ] Married [ ] Separated [ ] Widowed ₂₀Blood Type

₂₁If married, name of spouse

Last Name First Name Middle NameAge

Contact No. Mobile No.( )Area Code

Address if different

3. FAMILY INFORMATIONFATHER ₂₂PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED

23Is he the Primary Wage earner of Family [ ] YES [ ] NO 24Age

₂₅Father’s NameLast Name First Name Middle Name

₂₆Father’s Address



₂₇Father’s Telephone

Numbers


Office ( )Area Code

Mobile No. 1

( )Area Code

Mobile No. 2

( )Area Code

₂₈Father’s e-mail Address(s) 1. ____________________________________ 2. ____________________________________

₂₉Father’s education

Highest educational attainment ______________________________________________School/course/years attended or graduated ____________________________________Year Graduated __________ Degree _________________________________________PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no

₃₀Father’s employment /

earning capacity

If employed, name of company/employer ______________________________________Location of employer_______________________________________________________Position in firm ________________________________ Years in firm ______________[ ] 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 of 38

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 Address

Street No. Street subdivision/Barangay City/Municipality


₃₆Mother’s Telephone

Numbers


Office ( )Area Code

Mobile No. 1

( )Area Code

Mobile No. 2

( )Area Code

₃₇Mother’s e-mail Address(s) 1. ____________________________________ 2. ____________________________________

₃₈Mother’s education


₃₉Mother’s employment /

earning capacity


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 Address



₃₆Guardian’s Telephone

Numbers


Office ( )Area Code

Mobile No. 1 ( )

Area Code

Mobile No. 2 ( )

Area Code

₃₇Guardian’s e-mail Address(s) 1. ____________________________________ 2. ____________________________________

₄₇Guardian’s education


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₄₈Guardian’s employment /

earning capacity


If Guardian is primary wage earner AND currently UNEMPLOYED, please attach a separate letter explaining when last employed and reason for

unemployment

₄₉Person to Contact in case of

emergency

[ ] Father [ ] Mother [ ] Guardian [ ] Spouse [ ] Other (please specify name) ________________________________________

₅₀Emergency Contact Address



₅₁Emergency Contact Telephone Numbers

Residence

( )Area Code Office

( )Area Code

Mobile No. 1

( )Area Code Mobile No. 2

( )Area Code

₅₂SIBLING’S EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a separate sheet if neededNAME Age School last attended Year Level Course Graduated

Attach a separate sheet if needed

4. APPLICANT ACADEMIC INFORMATION₅₄SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)Elementary School

Levels Attended Gr. _____ To ______

Address Period Covered 19 _____ to 20 ______High School Levels

Attended Yr. _____ To ______Address Period Covered 20 _____ to 20 ______

College Degree

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Address Period Covered 20 _____ to 20 ______Post Graduate(Including other College of Medicine)

Degree

Address Period Covered 20 _____ to 20 ______

₅₅List any HONORS OR PRIZES you have received for academic excellence in HS / College or at special events such as science contests, writing contests, etc. (indicate honors and year, ex. 2nd 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 ACTIVITIES₅₇List 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 neededPosition 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 YearIf A PARENT or SIBLING SENDS MONEY from outside the Philippines,

PLEASE LIST ONLY THE MONEY THEY SEND

6A. FAMILY INCOME If PARENT OR SIBLING SENDS MONEY from OVERSEAS, below LIST ONLY THE MONEY SENT

2014 2014 INCOME

ACTUALLY RECEIVED

2014 INCOME UNPAID or

OWED

PROJECTED INCOME for

2015 FatherMother

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Brothers Sisters

6A. FAMILY INCOME SUB-TOTAL

6B. Support from RELATIVES & FRIENDS For the following, ALSO fill out Section 27

2014 2014 INCOME

ACTUALLY RECEIVED

INCOME UNPAID or

OWED


2015 Grandparents

UnclesAunts

Other relativesFriends

OtherOther

6B. RELATIVES & FRIENDS SUB-TOTALAttach a separate sheet if needed

6C. PROFITS EARNED IN RP 2014 INCOME ACTUALLY RECEIVED

INCOME UNPAID or

OWED


2015 Profit on Business

Profit/Rentals on LandsRentals on Residence/Buildings

CommissionsRetirement Benefits/Pension

OTHEROTHER

6C. PROFITS EARNED Sub-total Attach a separate sheet if needed

6D. INTEREST INCOME FROM INVESTMENTS Interest on Savings accounts

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Interest on Time DepositInterest on Money Market PlacementsInterest on Market Value of Securities

Interest on StocksInterest on Foreign Currency Deposit

Interest on Other Investments:OTHEROTHER

6D. INTEREST Income Sub-totalAttach a separate sheet if needed

6E. Other LOCAL Income (specify):

2014 INCOME ACTUALLY RECEIVED

INCOME UNPAID or

OWED


2015 ____________________________________________________________________

6E. OTHER INCOME Sub-totalAttach a separate sheet if needed

8. REQUIRED Additional INFORMATION ABOUT Annual PAID Income of APPLICANT SCHOLAR

THIS INCLUDES SUPPORT RECEIVED BY THE APPLICANT from PART/FULL TIME WORK, or from RELATIVES, FRIENDS, DONORS, other SCHOLARSHIPS or other NON FAMILY SOURCES

Name of employer, relative, friends, scholarship or donor who helps you


UNPAID or OWED


2015

7. Total APPLICANT INCOME for 2014Attach a separate sheet if needed

10. REQUIRED INFORMATION on BORROWING FOR LIVING This includes money borrowed FOR LIVING EXPENSES from

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family, friends, banks, credit cards, credit unions, SSS, GSIS, PagIbig, etc.

LENDER

Total 2014 Amount

Borrowed

Total still UNPAID or

OWED

PROJECTED LOANS for

2015 Borrowed from FAMILY

Borrowed from FRIENDS Borrowed from SSS Borrowed from GSIS

Borrowed by Salary loan Other (specify): __________________________

Borrowed from BANKS (specify each)Bank 1 ___________________________________

Bank 2 ___________________________________

Bank 3 ___________________________________

Borrowed using CREDIT CARDS (specify each)Card 1 ___________________________________

Card 2 ___________________________________

Card 3 ___________________________________

8. Total LOANS FOR LIVING for 2014Attach a separate sheet if needed

12. TOTAL GROSS ANNUAL INCOME SUMMARY PLEASE COPY THE TOTALS FROM ABOVE


INCOME UNPAID or

OWED


2015 6A. FAMILY INCOME (page 8)

6B. RELATIVES & FRIENDS (page 8)

6C. PROFITS EARNED (page 9)

6D. INTEREST Income (page 9)

6E. OTHER INCOME (page 9)

7. Total APPLICANT INCOME (page 10)

8. Total LOANS FOR LIVING (page 10)

TOTAL GROSS ANNUAL

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INCOME =

14. REQUIRED Additional INFORMATION ABOUT GROSS INCOME OF FAMILY MEMBERS SENDING FROM ABROAD

If PARENT OR SIBLING SENDS MONEY from OVERSEAS, LIST THEIR GROSS INCOME below:

2014 GROSS FOREIGN INCOME

UNPAID or OWED

PROJECTED INCOME for rest of 2015

FatherMother

Brothers Sisters Other Other


15. TOTAL MONTHLY FAMILY EXPENSES (In Philippines only)If the applicant DOES NOT LIVE WITH THE FAMILY DURING SCHOOL YEAR ,DO NOT ADD APPLICANT DORM EXPENSES TO FAMILY EXPENSES BELOW

Instead, please ANSWER DORM SECTION below.

11A. BASIC MONTHLY FAMILY EXPENSES

2014 EXPENSES ACTUALLY

PAID

2014 EXPENSES UNPAID or

OWEDPROJECTED

COSTS for 2015 Food

GroceryHouse Rent

ElectricityWater

LPGTelephone (landline)

DSL/ Broadband of 38

Cable TVCell 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

MEDICINESMEDICAL 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/clothingFood purchased in school BY APPLICANT

Transportation costs to & from school BY APPLICANTXeroxing, etc. BY APPLICANT

______________________________________

11A. Sub-total for BASIC MONTHLY FAMILY EXPENSES


11B. MONTHLY LOAN PAYMENTS (banks, SSS, PagIbig, family, friends etc)

(please identify to whom/why paid and if loan is for business)

2014 ACTUALLY PAID

2014 UNPAID or OWED

PROJECTED COSTS for 2015

Mortgage Amortization________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11B. Sub-total for MONTHLY loan payments


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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

(please identify CARD)AVERAGE MONTHLY

PAID

AVERAGE MONTHLY UNPAID

BALANCE

PROJECTED MONTHLY

COSTS for 2015 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11C.Sub-total for MONTHLY credit card payments


11D. Other Monthly Payments (please identify to whom/why paid)

2014 ACTUALLY PAID

2014 UNPAID or OWED


________________________________________________________________________________________________________________________________________________________________________________

11D. Sub-total other monthly paymentsAttach a separate sheet if needed

11ABCD. TOTAL BASIC FAMILY EXPENSES per MONTH

(11A+11B+11C+11D)

11E. DORM SECTION: If YOU DO NOT LIVE WITH YOUR FAMILY (i.e. Dorm, shared apartment, room or coop, etc.), ANSWER BELOW:ADDRESS WHERE YOU STAYED WHILE IN SCHOOL HOW MANY DO YOU SHARE WITH?

IF YOU ARE MOVING CLOSER TO ASMPH, WHERE WILL YOU STAY NEXT? HOW MANY OTHERS WILL YOU SHARE WITH?

AVERAGE MONTHLY

ACTUALLY PAID

AVERAGE MONTHLY

UNPAID or OWED


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Share of Rent per month paid by applicantShare of condo dues paid by applicant

Share of Electricity/water/gasFood purchased while in school or hospitalFood purchased/delivered to dorm/condo

Transportation costs to/from dorm/condo/etc Transportation costs to/from parents

Xeroxing, etc.Internet in dorm or broadband

Books________________________________________________________________________________________

11E. Sub-total for DORMEXPENSES


11. TOTAL MONTHLY FAMILY EXPENSES (11A+11B+11C+11D+ 11E)

(Basic + Dorm)

TOTAL of MONTHLY FAMILY EXPENSES for 1 year

MONTHLY X 12 MONTHS =

16. TOTAL ANNUAL FAMILY EXPENSES (In Philippines only)

12A. TUITION PAID 2014Please list names of who is receiving tuition help

2014 ACTUALLY PAID

2014 UNPAID or OWED


1 APPLICANT2345678

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12B. ANNUAL NON-TUITION EXPENSES

2014 ACTUALLY PAID

2014 UNPAID or OWED


Withholding Tax (per year)Insurance Plans (compute per year)

SSS/GSIS/Pag-IbigPhilHealth (PARENTS & SIBLINGS)

PhilHealth (APPLICANT)HOSPITALIZATIONS or MEDICAL CARE (Please answer

SECTION 25 below)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Sub-total for ANNUAL family EXPENSES (12A+12B)

Total ANNUAL Expenses (monthly x 12) + (Annual) =

Summary of Total FAMILY LOAN / CREDIT Expenses2014 ACTUALLY

PAID2014 UNPAID

or OWEDPROJECTED

COSTS for 2015

YEARLY LOAN EXPENSESYEARLY CREDIT CARD EXPENSES

TOTAL DEBT of 38

17. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET

Please copy your totals and enter them below:

2014 ACTUALLY

PAID

2014 UNPAID or

OWED

PROJECTED COSTS for

2015

TOTAL GROSS ANNUAL INCOME from page 11 above

+ + +

TOTAL ANNUAL EXPENSES from bottom of page 15 above

-- -- --

SURPLUS/ LOSS FOR THE YEAR

NOTE IF FAMILY LOSS FOR THE YEAR IS SIGNIFICANTLY NEGATIVE

(I.E. YOUR FAMILY SPENDS MORE THAN 10% THAN IT EARNS)YOUR PARENTS ARE REQUIRED TO ATTACH A SPECIAL LETTER

EXPLAINING HOW THEY ARE ABLE TO PAY THIS.

DO NOT SKIP THIS STEP

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18. PERSONAL POSSESSIONS DECLARATIONPlease list all possessions worth more than P1, 000 that you

PERSONALLY use regularly even if you do not own them. Be VERY complete & clear - these details are subject to verification

Leave any item blank if not applicable

Item Name/brand/model #

If this is NOT exclusively for you, who else

uses itAcquired

When

ApproximateAcquisition

CostLaptop

PC / Tablet

Printer

External Hard Drive

Cellular phone1

Cellular phone2

Cellular phone3

DSL line

Wi-Fi account

Digital recorder

Broadband account

Tape recorder

TV set(s)

VHS/VCD/DVD

Refrigerators/Freezers

Microwave/Oven

Washing Machine/Dryer

Air conditioner

Piano/organ

Braces

Car (fill out section 19)

ASMPH Financial Aid APPLICATION – NEW – 2015-16 of 38

Jewelry/watch (specify):

Other (specify):

Other (specify):

Other (specify): Attach a separate sheet if needed

19. FAMILY HOUSEHOLD POSSESSIONS DECLARATIONPlease 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 applicableBrand(s) & Model(s) Acquired When Cost

TV sets

VHS/VCD/DVD

Stereo/Karaoke

Cellular phones

Laptop

PC

Printer

Refrigerators/ Freezers

Microwave/Oven

Washing Machine/Dryer

Air conditioner

Piano/organ

Other (specify):

Other (specify):

Other (specify): Attach a separate sheet if needed

20. Personal & Family MembershipsPlease 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 . ASMPH Financial Aid APPLICATION – NEW – 2015-16 of 38

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


21. Personal BANK ACCOUNTSPlease 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.

BankType of account

(savings/checking/atm) Acquired When Current balance


22. Family BANK ACCOUNTSPlease list ALL YOUR FAMILY’S BANK ACCOUNTS that they OWN or USE Be VERY complete & clear - these details may be subject to verification.

Bank

Type of account (savings/checking/atm)

Who uses the card

Acquired When

Current balance


23. Personal Credit or Debit CardsPlease 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.ASMPH Financial Aid APPLICATION – NEW – 2015-16 of 38

Credit or Debit Card Who Pays the Bill Acquired WhenCurrent Credit

Limit


24. Family Credit or Debit CardsPlease 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


25. Domestic OR International Travel By YOU Personally OR by Your IMMEDIATE FAMILY during the past 3 YEARS

This includes ALL INTERNATIONAL TRIPS and ANY LOCAL TRAVEL BY PLANE or MORE THAN 5 HOURS by CAR, BUS, etc. Leave blank if not applicable.

Be VERY complete & clear - details are subject to verification

Person(s) traveling & relationship to

you:

Purpose (vacation,

emergency, etc.)

Dates of trip Destination(s)

By Ship Airline,

Bus, or Car

Estimated

Cost of trip

Who paid for the trip?



26. Personal & Family Vehicle DeclarationPlease 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 SHOWINGTHE FRONT and SIDE of EACH VEHICLE

Make/Yr Model When Purchased Amt of Purchase Amt Paid ForCompany/

Family Owned


27. Family Properties Owned OR USED (residential, commercial, etc.)PLEASE ATTACH RECENT PHOTOGRAPHS of EACH PROPERTY or HOUSE SHOWING the OUTSIDE

(FRONT, BACK, SIDES) of the HOUSE or PROPERTY as well as the ROOMS INSIDE THE HOUSE.Description and/or use Location Size

Acquired When

Value at Acquisition

Present Market Value

Yearly Net Income


28. Siblings No Longer In School

Name AgeCivil

Status

Still residing

with you?

Highest educational

attainment & school attended

Where employed (Company & Location)*

Position in the

Firm**

Annual Gross

Income**


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

29. Serious Acute OR Chronic IllnessesIf 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.

Name Age Rela

tion

to

you

Diagnosis # of

tim

es

hosp

italiz

ed Currenttreatment /medicines

required

Est. annual

treatment cost

ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENTAttach a separate sheet if needed

30. Other Dependents Living In Your House

Name AgeCivil

StatusRelation to you

Reason for staying with

family

Where employed (Company & Location)*

Position in the

Firm**

Annual Gross

Income**

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

31. Relatives, Friends, Etc. Who Help With Household & Educational Expenses

Indicate duration and extent of financial support (for whom, how much per month/year).Name Relation to

youWho

receives Help for

whatWhen did they start

How much per

Total per

If they will not continue, why


help helping month year


32. Scholarships & Educational PlansAre any of your siblings presently or PREVIOUSLY on scholarship in any school : Yes No

Sibling SchoolMerit/ Athletic/

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?


33. Emigration & OFW DeclarationAre any of your immediate family members under petition for immigration or

have any pending visa application to another country Yes No

If so, please indicate the names of those who are leaving and give brief details.

____________________________________________________________________________________________________

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.

____________________________________________________________________________________________________

34. Working Student DeclarationIf 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?

35. Your Experience with MedicinePlease 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, orhospitalized children or adults?

Yes No

Have you ever joined a medical mission or Yes NoASMPH Financial Aid APPLICATION – NEW – 2015-16 of 38

helped during any medical procedures?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 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 rateHOW DO YOU FEEL ABOUT THE

FOLLOWING:

Un-happy

Very Confident

1 2 3 4 5Going to school for 10 or more years

Classes are really difficult. Being dependent on your family

for another 5-10 years

Medical lifestyle with hours that are long Going to class from early morning to early evening

Studying for hours every day of the week Loss of independence or carefree college lifestyle

5 year mandatory service requirement for ASMPH scholars

ASMPH Scholar requirement to find support for a new ASMPH scholar within 20 years

after ASMPH graduation

Getting through medical school requires giving up many things. On a scale of 1 to 5, please rate

HOW WILLING YOU ARE TO GIVE UP THE FOLLOWING:Won't give up 2 3 4 Willing to

give up NA

Your boyfriend/girlfriend?

Your weekends?

Your co-curriculars or orgs or


non-worship church activities?going to movies

going to gimmicks or parties

reading non medical literature

watching TV or DVDs

Seeing your family as often?

On a scale from 1 to 5, please rate the following:How much do your parents

WANT you to go to medical school?Against

my going 1 2 3 4 5 TOTALLY determined

How IMPORTANT is it to your parentsthat you become a doctor?

Not important 1 2 3 4 5 Very

important

How much did your PARENTS Influence you to become a doctor?

No influence 1 2 3 4 5 Highly

influenced

How much did your CLASSMATES or COURSE influence you

to become a doctor?

No influence 1 2 3 4 5 Highly

influenced

How OFTEN do you have DOUBTSabout going to medical school? No doubts 1 2 3 4 5 Frequent

doubtful

How STRONG is your COMMITMENTto FINISHING medical school?

Unsure if I'll finish) 1 2 3 4 5 Totally

committed

How much you REALLYwant to go to medical school?

Will go if accepted 1 2 3 4 5 totally

determined

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

Do you plan to have a family? Yes NoDo you wish to travel during or after medical school? Yes No

Have you ever thought about starting a business? Yes NoAre you willing to practice in your province

after graduation or residency? Yes No

Where do you plan to work as a doctor after graduation and why?


Please list all the medical schools have you applied to and rank them from first choice to last?

If you do not get financial aid, what will you do?

36. OTHER INFORMATIONList 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.

37. Persons to Recommend YouList 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__________________________________________________________________________________________________________________________________________________________

38. PERSONAL NEEDS ESSAY (ANSWER BELOW)In order for the Financial Aid Committee to understand your needs,

PLEASE WRITE WHY YOU NEED FINANCIAL AID. Please describe clearly and simply about you and your family’s needs

You must be honest and complete. Do NOT write your admission essay or a request for financial aid.

Your MUST explain WHY you and your family NEED FINANCIAL AID. All information you give is confidential


and will not be shared with anyone without your written permission.(Guidelines: 2-3 pages, single-spaced, Times New Roman font, and 12 pt.)

Type your ESSAY here:


39. 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

Pix label = Pix label =





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







Ateneo de Manila UniversitySchool of Medicine and Public Health

Financial Aid Application Form

I/we hereby certify that all information written in this application is complete and accurate and we are hereby authorized to verify the same.

I/we understand that during the period of any scholarship granted: misrepresentation of information or withholding of information requested for my application


will be considered reason for disapproval or cancellation of financial aid and, where appropriate, grounds for legal action ,

as well as referral to the Dean for charges of Academic Dishonesty with the potential of Dishonorable Dismissal with mandatory repayment of all grants paid, with interest.

I agree if accepted as a scholar that my admission, matriculation, and graduation are subject to the rules and regulations of the Ateneo de Manila University.

________________________________________________________ Applicant’s Signature Date

________________________________________________________ Parent’s or Guardian’s Signature Date



APPLICANT’S FINANCIAL AUTHORIZATION FORM 2015 – 2016APPLICANT NAME __________________________________________________________________________(Name in Birth Certificate) Last Name First Name Middle Name

I, _____________________________________, hereby certify that all information written in this application or submitted in support of this application is complete and accurate.I understand that during the period of any grant given, misrepresentation of information or withholding of information requested for my application will be considered reason for disapproval or cancellation of financial aid and, where appropriate, grounds for legal action, as well as referral to the Dean for charges of Academic Dishonesty with the potential of Dishonorable Dismissal with mandatory repayment of all grant monies paid.

I hereby authorize the Ateneo School of Medicine and Public Health (ASMPH) to confirm through investigation any information provided by me for my application for ASMPH financial aid from whatever sources the school may consider appropriate.

I hereby give permission for physical evaluation that may include, but is not limited to, unannounced site visits of my family's permanent residence, real estate, and my dormitory, with physical inventory of our home and my dorm contents and assets.

I also give specific permission to obtain personal financial information from the BIR, the LTO, PhilHealth, DOLE, local and international banks, and any other source of information pertinent to my application for financial aid.

I consent to the use and disclosure by the Ateneo of information in and relating to my application, to any of its subsidiaries and affiliates, agents, banks and banking associations, credit card companies and associations, financial institutions, credit information bureaus and their equivalent, third-party service providers rendering services to the Ateneo, as well as third parties authorized by the ASMPH to receive such information, wherever situated, for confidential use in connection with the exercise of its functions to provide financial aid (including but not limited to credit investigation and collection, information technology systems and processes, data processing, imaging and storage, back-up and recovery and risk analyses purposes).

I agree that such disclosure or exchange of information shall not be the basis of any claim against the School or the parties to whom the School makes the disclosure.

I acknowledge that the School may disclose any information or data regarding my application upon orders of courts or requests of competent government offices or agencies authorized by law.

I hereby give permission for the School to request information and to make necessary inquiries about me and my family from third parties in connection with my application for financial aid.

I agree if accepted as a scholar that my admission, matriculation, and graduation are subject to the rules and regulations of the Ateneo de Manila University

_________________________________________________________ Applicant’s Signature over printed name Date



PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 2015 – 2016APPLICANT NAME __________________________________________________________________________(Name in Birth Certificate) Last Name First Name Middle 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.

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/Guardian’s Signature over printed name / Date Parent’s Signature over printed name / Date


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