Asmph Fa Application - New Student - 2015-16 Final

Ateneo de Manila University School of Medicine and Public HealthFinancial Aid Application Form Financial Aid Application Form SY 2015 - 2016THIS 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

Page 2 of 37

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 FAMILYS 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 applicationi. PERMANENT and LOCAL HOUSES/APARTMENTS/ CONDOS/ FARMS / etc (whether owned, borrowed, loaned, or rented) where you stay showing the OUTSIDE (FRONT, BACK, SIDES) of the HOUSE or apartment as well as the ROOMS INSIDE.ii. EACH VEHICLE (whether owned, borrowed, loaned, or rented) showing the FRONT and SIDE of EACH VEHICLEiii. EACH PROPERTY, LOT, or HOUSE (other than PERMANENT or LOCAL RESIDENCES) (whether owned, borrowed, loaned, or rented) SHOWING the OUTSIDE (front, back, sides) of the HOUSE or PROPERTY as well as the ROOMS inside the house.3. To be submitted BEFORE or AT THE INTERVIEW:a. Certificate of Employment & Compensation for currently employed parents, sibilings or applicants (including bonuses, commissions, and 13th month pay allowances) for the current year from current employer/company for each employed parent and sibling of the applicant still residing with the family;b. If parents are self-employed, please submit a detailed description of the business and an income & expense financial statement for the year;c. If parents were retired or RETRENCHED IN the past three years, please submit a copy of certification indicating amount of retirement or separation benefits, if received.d. Latest income tax return for each employed/self-employed parent of applicant. If not available, please explain in your PERSONAL ESSAY;4. All information will be kept STRICTLY confidential.5. Place your documents in a SEALED LEGAL SIZE BROWN ENVELOPE LABELED with YOUR NAME (LAST, FIRST, MI) IN THE UPPER LEFT CORNER

Submit these documents to: ASMPH Financial Aid Committee Registrars 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 Last name, first, MI TO: ASMPH Financial Aid Committee Registrars Office, ASMPH , Ortigas Ave. 1604, Pasig CityParents and/or Applicants Certificate of employment OR Parents and/or Applicants Self-employed Business description & balance sheets or Retirement or retrenchment information BIR I.T.R. FOR 2014 Legal size brown envelope Applicants 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 - 2016

THIS FORM IS ONLY FOR NEW APPLICANTS PLEASE TYPE / COPYPASTE, PRINT & SUBMIT IN HARD COPY Do Not EMAIL

Please PASTE a SOFT or HARD copy of Recent 2 x 2 Photo of The Applicant(IF HARD COPY, PLEASE WRITE YOUR NAME AT THE BACK)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 NameFirst NameMiddle Name

Nickname ____________________ School ________________________________________________________

Degree _______________________________________________________Date of graduation ______________

Cumulative QPI/GPAwhere highest grade is equivalent to 4 5 1

NMAT%taken when Part I%Part I%

VerbalInductive ReasoningQuantitativePerceptual Acuity

BiologyPhysicsSocial ScienceChemistry

Are you graduating with HONORS?[ ] No [ ] Yes, I graduated/expect to graduate: [ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention

1. SCHOLARSHIP REQUEST PERCENTAGE GRANT REQUESTED 100% TF 90% TF 80% TF 70% TF 60% TF 50% TF 40% TF 30% TF 20% TF 10% TF

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

If you received financial aid in COLLEGE, how much did you receive? (check all that apply) 100TF 75TF 50TF 25TF _____Dorm Books Food _________

2. PERSONAL INFORMATIONPermanent Address

Street No. Street Subdivision/Barangay City/Municipality

Province Country ZIP code

Mailing Address(If not the same as permanent add.)

Street No. Street Subdivision/Barangay City/Municipality


LOCAL Address where you stay during school

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

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

Applicants phone NumbersResidence( )Area CodeOffice( )Area Code

Mobile No. 1( )Area CodeMobile No. 2( )Area Code

E-mail Address(s)1. ________________________________________________2. ________________________________________________Gender[ ] Male [ ] Female

Date of Birth(MM/DD/YEAR)AgePlace of Birth

Citizenship[ ] Filipino [ ] Others, pls. specify PhilHealth[ ] Yes [ ] No

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

If married, name of spouse Last Name First Name Middle NameAge

Contact No.

Mobile No.( )Area CodeAddress if different

3. FAMILY INFORMATIONFATHERPlease indicate if:[ ] Single Parent [ ] Widowed [ ] Separated [ ] DECEASED

23Is he the Primary Wage earner of Family[ ] Yes [ ] No24Age

Fathers NameLast Name First Name Middle Name

Fathers AddressStreet No. Street Subdivision/Barangay City/Municipality


Fathers TelephoneNumbersResidence( )Area CodeOffice( )Area Code


Fathers e-mail Address(s)1. ____________________________________ 2. ____________________________________

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

Fathers employment / earning capacityIf 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 separate letter explaining when last employed and reason for unemployment

MOTHERPlease indicate if:[ ] Single Parent [ ] Widowed [ ] Separated [ ] DECEASED

Is she the Primary Wage earner of Family[ ] Yes [ ] NoAge

Mothers NameLast Name First Name Middle Name

Mothers AddressStreet No. Street subdivision/Barangay City/Municipality


Mothers TelephoneNumbersResidence( )Area CodeOffice( )Area Code


Mothers e-mail Address(s)1. ____________________________________ 2. ____________________________________

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

Mothers employment / earning capacityIf 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 Mother is primary wage earner AND currently UNEMPLOYED, please attach a separate letter explaining when last employed and reason for unemployment

GUARDIAN (If applicable)Relationship to you:

Is he/she responsible for your financial needs :[ ] Yes [ ] NoAge

Guardians NameLast Name First Name Middle Name

Guardians AddressStreet No. Street Subdivision/Barangay City/Municipality


Guardians TelephoneNumbersResidence( )Area CodeOffice( )Area Code


Guardians e-mail Address(s)1. ____________________________________ 2. ____________________________________

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

Guardians employment / earning capacityIf 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 Guardian is primary wage earner AND currently UNEMPLOYED, please attach a separate letter explaining when last employed and reason for unemployment

Person to Contact in case of emergency[ ] Father [ ] Mother [ ] Guardian [ ] Spouse [ ] Other (please specify name) ________________________________________

Emergency Contact AddressStreet No. Street Subdivision/Barangay City/Municipality


Emergency Contact Telephone NumbersResidence( )Area CodeOffice( )Area Code


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

NAMEAgeSchool last attendedYear Level CourseGraduated

Attach a separate sheet if needed

4. APPLICANT ACADEMIC INFORMATIONSCHOOLS ATTENDED (List all schools attended beginning from lowest grade)

Elementary School

Levels AttendedGr. _____ To ______

AddressPeriod Covered19 _____ to 20 ______

High School

Levels AttendedYr. _____ To ______


College

Degree


Post Graduate(Including other College of Medicine)Degree


List 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 ACTIVITIESList your college extra-curricular activities, including positions held or special responsibilities and year. (e. Dramatics 1,2,3,4; Class Secretary 2,4; Basketball Varsity 1,3) Attach a separate sheet if needed

List your community and / or church activities. Attach a separate sheet if needed

Other work experience after graduation from College - Attach a separate sheet if needed

PositionCompany and AddressDate

Were you ever dismissed, suspended or placed on probation? [ ] Yes [ ] No If Yes, specify dates, offenses, penalties ______________________________________________Please attach a separate sheet explaining the circumstances

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 SENT2014 2014 INCOME ACTUALLY RECEIVED2014 INCOME UNPAID or OWEDPROJECTED INCOME for 2015

Father

Mother

Brothers

Sisters

6A. FAMILY INCOME SUB-TOTAL

6B. Support from RELATIVES & FRIENDS For the following, ALSO fill out Section 272014 2014 INCOME ACTUALLY RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015

Grandparents

Uncles

Aunts

Other relatives

Friends

Other

Other

6B. RELATIVES & FRIENDS SUB-TOTAL


6C. PROFITS EARNED IN RP2014 INCOME ACTUALLY RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015

Profit on Business

Profit/Rentals on Lands

Rentals on Residence/Buildings

Commissions

Retirement Benefits/Pension

OTHER

OTHER

6C. PROFITS EARNED Sub-total


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


6E. Other LOCAL Income (specify): 2014 INCOME ACTUALLY RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015

__________________________________

__________________________________

6E. OTHER INCOME Sub-total


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

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

Name of employer, relative, friends, scholarship or donor who helps you2014 INCOME ACTUALLY RECEIVEDUNPAID or OWEDPROJECTED INCOME for 2015

7. Total APPLICANT INCOME for 2014


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.

LENDERTotal 2014 Amount BorrowedTotal still UNPAID or OWEDPROJECTED LOANS for 2015

Borrowed from FAMILY

Borrowed from FRIENDS

Borrowed from SSS

Borrowed from GSIS

Borrowed by Salary loan

Other (specify): __________________________

Borrowed from BANKS (specify each)

Bank 1 ___________________________________

Bank 2 ___________________________________

Bank 3 ___________________________________

Borrowed using CREDIT CARDS (specify each)

Card 1 ___________________________________

Card 2 ___________________________________

Card 3 ___________________________________

8. Total LOANS FOR LIVING for 2014


9. Total Gross Annual Income SUMMARY

PLEASE COPY THE TOTALS FROM ABOVE 2014 INCOME ACTUALLY RECEIVEDINCOME UNPAID or OWEDPROJECTED INCOME for 2015

6A. FAMILY INCOME (page 8)

6B. RELATIVES & FRIENDS (page 8)

6C. PROFITS EARNED (page 9)

6D. INTEREST Income (page 9)

6E. OTHER INCOME (page 9)

7. Total APPLICANT INCOME (page 10)

8. Total LOANS FOR LIVING (page 10)

Total Gross Annual Income =

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

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

2014 GROSS FOREIGN INCOMEUNPAID or OWEDPROJECTED INCOME for rest of 2015

Father

Mother

Brothers

Sisters

Other

Other


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 BELOWInstead, please ANSWER DORM SECTION below.

11A. BASIC MONTHLY FAMILY EXPENSES2014 EXPENSES ACTUALLY PAID2014 EXPENSES UNPAID or OWEDPROJECTED COSTS for 2015

Food

Grocery

House Rent

Electricity

Water

LPG

Telephone (landline)

DSL/ Broadband

Cable TV

Cell phone Load (Do NOT include Applicant)

Non-school Clothing (Do NOT include Applicant)

School Uniforms/clothing (Do NOT include Applicant)

Transportation (PARENTS)

Transportation (SIBLINGS ONLY)

School Bus or car pool (SIBLINGS ONLY)

Salaries of helper, housekeeper, driver, etc. working only for family

(if total FOR MEDICINES or MEDICAL TREATMENTS is P500 per month or GREATERYOU MUST fill out Section 25 BELOW

MEDICINES

MEDICAL TREATMENTS

MONTHLY EXPENSES FOR APPLICANT LIVING WITH FAMILY (IF APPLICANT LIVES IN A DORM NOW THEN SKIP THIS SECTION AND ANSWER IN DORM SECTION BELOW)

Cell phone load

Non school Clothing

School Uniforms/clothing

Food purchased in school BY APPLICANT

Transportation costs to & from school BY APPLICANT

Xeroxing, etc. BY APPLICANT

______________________________________

11A. Sub-total for BASIC MONTHLY FAMILY EXPENSES


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

(please identify to whom/why paid and if loan is for business)2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015

Mortgage Amortization

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

11B. Sub-total for MONTHLY loan payments


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 PAIDAVERAGE MONTHLY UNPAID BALANCEPROJECTED MONTHLY COSTS for 2015

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

11C.Sub-total for MONTHLY credit card payments


11D. Other Monthly Payments (please identify to whom/why paid)2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015

____________________________________________

____________________________________________

____________________________________________

____________________________________________

11D. Sub-total other monthly payments


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 SCHOOLHOW 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 PAIDAVERAGE MONTHLY UNPAID or OWEDPROJECTED COSTS for 2015

Share of Rent per month paid by applicant

Share of condo dues paid by applicant

Share of Electricity/water/gas

Food purchased while in school or hospital

Food purchased/delivered to dorm/condo

Transportation costs to/from dorm/condo/etc

Transportation costs to/from parents

Xeroxing, etc.

Internet in dorm or broadband

Books

____________________________________________

____________________________________________

11E. Sub-total for DORMEXPENSES


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

TOTAL of MONTHLY FAMILY EXPENSES for 1 year

MONTHLY X 12 MONTHS =

12. Total ANNUAL FAMILY Expenses (In Philippines only)

12A. TUITION PAID 2014Please list names of who is receiving tuition help2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015

1 APPLICANT

2

3

4

5

6

7

8


12B. ANNUAL NON-TUITION EXPENSES2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015

Withholding Tax (per year)

Insurance Plans (compute per year)

SSS/GSIS/Pag-Ibig

PhilHealth (PARENTS & SIBLINGS)

PhilHealth (APPLICANT)

HOSPITALIZATIONS or MEDICAL CARE (Please answer SECTION 25 below)

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

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

Total ANNUAL Expenses

(monthly x 12) + (Annual) =

Summary of Total FAMILY LOAN / CREDIT Expenses

2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED COSTS for 2015

YEARLY LOAN EXPENSES

YEARLY CREDIT CARD EXPENSES

TOTAL DEBT

13. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET

Please copy your totals and enter them below:2014 ACTUALLY PAID2014 UNPAID or OWEDPROJECTED 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

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

ItemName/brand/model #If this is NOT exclusively for you, who else uses itAcquired WhenApproximateAcquisition Cost

Laptop

PC / Tablet

Printer

External Hard Drive

Cellular phone1

Cellular phone2

Cellular phone3

DSL line

Wi-Fi account

Digital recorder

Broadband account

Tape recorder

TV set(s)

VHS/VCD/DVD

Refrigerators/Freezers

Microwave/Oven

Washing Machine/Dryer

Air conditioner

Piano/organ

Braces

Car (fill out section 19)

Jewelry/watch (specify):

Other (specify):

Other (specify):

Other (specify):


15. 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 applicable

Brand(s) & Model(s)Acquired WhenCost

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):


16. 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. Memberships can be in gym, golf club, sports club, etc. Be VERY complete & clear - these details are subject to verification.

MembershipFor what purposeAcquired WhenCost

Attach a separate sheet if needed17. 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 WhenCurrent balance

Attach a separate sheet if needed18. Family BANK ACCOUNTSPlease list ALL YOUR FAMILYS 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 cardAcquired WhenCurrent balance


19. 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.

Credit or Debit CardWho Pays the BillAcquired WhenCurrent Credit Limit

Attach a separate sheet if needed20. 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 CardWho uses the cardWho Pays the BillAcquired WhenCurrent Credit Limit

Attach a separate sheet if needed21. Domestic OR International Travel By YOU Personally OR by Your IMMEDIATE FAMILY during the past 3 YEARSThis 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 tripDestination(s)By Ship Airline, Bus, or Car EstimatedCost of tripWho paid for the trip?

Attach a separate sheet if needed22. 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 ModelWhen PurchasedAmt of PurchaseAmt Paid ForCompany/Family Owned

Attach a separate sheet if needed23. 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 useLocationSizeAcquired WhenValue at AcquisitionPresent Market ValueYearly Net Income

Attach a separate sheet if needed24. Siblings No Longer In SchoolNameAgeCivil StatusStill residing with you?Highest educational attainment & school attendedWhere employed (Company & Location)*Position in the Firm**Annual Gross Income**

Attach a separate sheet if needed *If unemployed, state reason.**Do not leave blank.25. 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.

NameAgeRelation to youDiagnosis# of times hospitalizedCurrenttreatment /medicines requiredEst. annual treatment cost

Attach a separate sheet with Summary History of Present Illness for each patient

Attach a separate sheet if needed26. Other Dependents Living In Your House

NameAgeCivil StatusRelation to youReason for staying with familyWhere employed (Company & Location)*Position in the Firm**Annual Gross 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).

NameRelation to youWho receives helpHelp for whatWhen did they start helpingHow much per monthTotal per yearIf they will not continue, why

Attach a separate sheet if needed28. Scholarships & Educational PlansAre any of your siblings presently or PREVIOUSLY on scholarship in any school :Yes No

SiblingSchoolMerit/ Athletic/ Financial aidHow much is granted?

Are YOU or any of your siblings enrolled under an education plan in any school :Yes No

SiblingSchoolCompanyHow much?

Attach a separate sheet if needed29. 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.__________________________________________________ __________________________________________________

30. 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?

31. 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 helped during any medical procedures? Yes No

Have you visited any medical schools prior to applying to ASMPH? Yes No

Have you ever been a patient in a hospital? Yes No

Are any of your relatives actively working as doctors? Yes No

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-happyVery Confident

12345

Going to school for 10 or more years

Classes are really difficult.

Being dependent on your family for another 5-10 years

Medical lifestyle with hours that are long

Going to class from early morning to early evening

Studying for hours every day of the week

Loss of independence or carefree college lifestyle

5 year mandatory service requirement for ASMPH scholars

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

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 up234Willing to give upNA

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 parentsWANT you to go to medical school?Against my going12345TOTALLY determined

How IMPORTANT is it to your parentsthat you become a doctor?Not important12345Very important

How much did your PARENTS Influence you to become a doctor?No influence12345Highly influenced

How much did your CLASSMATES or COURSE influence you to become a doctor?No influence12345Highly influenced

How OFTEN do you have DOUBTSabout going to medical school?No doubts12345Frequent doubtful

How STRONG is your COMMITMENTto FINISHING medical school?Unsure if I'll finish)12345Totally committed

How much you REALLYwant to go to medical school?Will go if accepted12345totally 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

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

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

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

32. OTHER 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.

33. 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

_____________________________________________________________________________ _____________________________________________________________________________

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 familys needsYou 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:

35. SOFT OR HARD COPIES OF PICTURES OF CARS, HOMES, DORM, ETC (label each clearly)

Paste soft copies of picture herePaste soft copies of picture here

Pix label =Pix label =





























Ateneo de Manila UniversitySchool of Medicine and Public HealthFinancial 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.

________________________________________________________ Applicants Signature Date

________________________________________________________ Parents or Guardians Signature Date

Ateneo de Manila UniversitySchool of Medicine and Public Health

APPLICANTS FINANCIAL AUTHORIZATION FORM 2015 2016

APPLICANT NAME __________________________________________________________________________(Name in Birth Certificate) Last NameFirst NameMiddle Name

ASMPH Financial Aid APPLICATION NEW 2015-16 Page 4 of 37I, _____________________________________, 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

_________________________________________________________ Applicants Signature over printed name Date

Ateneo de Manila UniversitySchool of Medicine and Public Health

PARENTAL or GUARDIAN FINANCIAL AUTHORIZATION FORM 2015 2016

APPLICANT NAME __________________________________________________________________________(Name in Birth Certificate) Last NameFirst NameMiddle Name

ASMPH Financial Aid APPLICATION NEW 2015-16 Page 37 of 37I/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 childs 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/Guardians Signature over printed name / Date Parents Signature over printed name / Date

Documents

Asmph Fa Application - New Student - 2015-16 Final