Post on 17-Mar-2018
Financial Aid Application FormFinancial Aid Application Form – SY 20__ - 20__
THIS FORM IS ONLY FOR NEW APPLICANTS
ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED
FOR ONLY ONE YEAR, RENEWABLE ANNUALLY.
ANY FINANCIAL AID GRANT =TUITION & FEES COST – FAMILY CONTRIBUTION.
ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE BURDEN AS POSSIBLE.
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
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i. 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 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 c/o Admissions 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”
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Last name, first, MI
TO: ASMPH Financial Aid Committee
Registrar’s Office, ASMPH ,
Financial Aid Application Form – SY 2015 - 2016THIS FORM IS ONLY FOR NEW APPLICANTS
PLEASE TYPE / COPYPASTE, PRINT & SUBMIT IN HARD COPY – Do Not EMAIL
ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED FOR ONLY ONE YEAR, RENEWABLE 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
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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)
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% TF50% 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.)
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code₉LOCAL Address where you stay
during school Street No. Street Subdivision/Barangay City/Municipality ZIP code
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
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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 Name
Age
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
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
₂₇Father’s Telephone
Numbers
Residence ( )Area Code
Office ( )Area Code
Mobile No. 1
( )Area Code
MobileNo. 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 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
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₃₅Mother’s Address
Street No. Street subdivision/Barangay City/Municipality
Province Country ZIP code
₃₆Mother’s Telephone
Numbers
Residence ( )Area Code
Office ( )Area Code
Mobile No. 1
( )Area Code
MobileNo. 2
( )Area Code
₃₇Mother’s e-mail Address(s) 1. ____________________________________ 2. ____________________________________
₃₈Mother’s education
Highest educational attainment ______________________________________________School/course/years attended or graduated ____________________________________Year Graduated __________ Degree _________________________________________PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no
₃₉Mother’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 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
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
₃₆Guardian’s Telephone
Numbers
Residence ( )Area Code
Office ( )Area Code
Mobile No. 1 ( )
Area Code
MobileNo. 2 ( )
Area Code
₃₇Guardian’se-mail Address(s) 1. ____________________________________ 2. ____________________________________
₄₇Guardian’s education
Highest educational attainment ______________________________________________School/course/years attended or graduated ____________________________________Year Graduated __________ Degree _________________________________________PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no
₄₈Guardian’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 ______________________________________________
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Do you [ ] own or [ ] share ownership of this business?
If Guardian is primary wage earner AND currently UNEMPLOYED, please attach a separate letter explaining when last employed and reason for
unemployment
₄₉Person to Contact in case of
emergency
[ ] Father [ ] Mother [ ] Guardian [ ] Spouse[ ] Other (please specify name) ________________________________________
₅₀Emergency Contact Address
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
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
Address Period Covered 20 _____ to 20 ______Post Graduate Degree
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(Including other College of Medicine)
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
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
2014 INCOME UNPAID or
OWED
PROJECTED INCOME for
2015
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RECEIVED FatherMother
Brothers Sisters
6A. FAMILY INCOME SUB-TOTAL
6B. Support fromRELATIVES & FRIENDSFor the following, ALSO fill out Section 27
2014 2014 INCOME
ACTUALLY RECEIVED
INCOME UNPAID or
OWED
PROJECTED INCOME for
2015Grandparents
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
PROJECTED INCOME for
2015 Profit on Business
Profit/Rentals on LandsRentals on Residence/Buildings
CommissionsRetirement Benefits/Pension
OTHEROTHER
6C. PROFITS EARNED Sub-total
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Attach a separate sheet if needed
6D. INTEREST INCOME FROM INVESTMENTSInterest on Savings accounts
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
PROJECTED INCOME for
2015____________________________________________________________________
6E. OTHER INCOME Sub-totalAttach a separate sheet if needed
8. REQUIRED Additional INFORMATION ABOUTAnnual 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
2014 INCOME ACTUALLY RECEIVED
UNPAID or OWED
PROJECTED INCOME for
2015
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7. Total APPLICANT INCOME for 2014Attach a separate sheet if needed
10. REQUIRED INFORMATION on BORROWING FOR LIVINGThis includes money borrowed FOR LIVING EXPENSES from
family, friends, banks, credit cards, credit unions, SSS, GSIS, PagIbig, etc.
LENDER
Total 2014 Amount
Borrowed
Total still UNPAID or
OWED
PROJECTED LOANS for
2015Borrowed from FAMILY
Borrowed from FRIENDS Borrowed from SSSBorrowed 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
2014 INCOME ACTUALLY RECEIVED
INCOME UNPAID or
OWED
PROJECTED INCOME for
20156A. FAMILY INCOME (page 8)
6B. RELATIVES & FRIENDS (page 8)
6C. PROFITS EARNED (page 9)
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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 =
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
Attach a separate sheet if needed
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.
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11A. BASIC MONTHLY FAMILY EXPENSES
2014 EXPENSES ACTUALLY
PAID
2014 EXPENSES UNPAID or
OWEDPROJECTED
COSTS for 2015Food
GroceryHouse Rent
ElectricityWater
LPGTelephone (landline)
DSL/ BroadbandCable 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 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 loadNon 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
Attach a separate sheet if needed
11B. MONTHLY LOAN PAYMENTS (banks, SSS, PagIbig, family, friends etc)
Page 14 of 41
(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
Attach a separate sheet if needed
11C. AVERAGE MONTHLY CREDIT CARD PAYMENTSURGENT: 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 MONTHLYcredit card payments
Attach a separate sheet if needed
11D. Other Monthly Payments (please identify to whom/why paid)
2014 ACTUALLY PAID
2014 UNPAID or OWED
PROJECTED COSTS for 2015
________________________________________________________________________________________________________________________________________________________________________________
11D. Sub-total other monthly paymentsAttach a separate sheet if needed
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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 WILLYOU SHARE WITH?
AVERAGE MONTHLY
ACTUALLY PAID
AVERAGE MONTHLY
UNPAID or OWED
PROJECTED COSTS for 2015
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/etcTransportation costs to/from parents
Xeroxing, etc.Internet in dorm or broadband
Books________________________________________________________________________________________
11E. Sub-total for DORMEXPENSES
Attach a separate sheet if needed
11. TOTAL MONTHLY FAMILY EXPENSES (11A+11B+11C+11D+ 11E)
(Basic + Dorm)
TOTAL of MONTHLY FAMILY EXPENSES for 1 yearPage 16 of 41
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
PROJECTED COSTS for 2015
1 APPLICANT2345678
Attach a separate sheet if needed
12B. ANNUAL NON-TUITION EXPENSES
2014 ACTUALLY PAID
2014 UNPAID or OWED
PROJECTED COSTS for 2015
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)
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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
17. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET
Please copy your totals andenter 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 Page 18 of 41
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 LETTEREXPLAINING
HOW THEY ARE ABLE TO PAY THIS.DO NOT SKIP THIS STEP
Page 19 of 41
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
ASMPH Financial Aid APPLICATION – NEW – version November 2015 Page 20 of 41
Car (fill out section 19)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
ASMPH Financial Aid APPLICATION – NEW – version November 2015 Page 21 of 41
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 . Memberships can be in gym, golf club, sports club, etc. Be VERY complete & clear -
these details are subject to verification.Membership For what purpose Acquired When Cost
Attach a separate sheet if needed
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
Attach a separate sheet if needed
22. Family BANK ACCOUNTSPlease list ALL YOUR FAMILY’S BANK ACCOUNTS that they OWN or USEBe 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
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION – NEW – version November 2015 Page 22 of 41
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.
Credit or Debit Card Who Pays the Bill Acquired WhenCurrent Credit
Limit
Attach a separate sheet if needed
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
Attach a separate sheet if needed
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 TRAVELBY 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?
ASMPH Financial Aid APPLICATION – NEW – version November 2015 Page 23 of 41
Attach a separate sheet if needed
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
Attach a separate sheet if needed
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
ASMPH Financial Aid APPLICATION – NEW – version November 2015 Page 24 of 41
Attach a separate sheet if needed
28. Siblings No Longer In School
Name AgeCivil
Status
Still residing
withyou?
Highesteducational
attainment &school attended
Where employed (Company & Location)*
Positionin 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**
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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).
NameRelation to
you
Who receives
helpHelp for
what
When did they start
helping
How much per
month
Total per year
If they will not continue, why
Attach a separate sheet if needed
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?
Attach a separate sheet if needed
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?
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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 orhelped 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 oryour doctor or teacher?
Yes No
Have you ever spent time with a doctor relativewhile 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 requirementfor ASMPH scholars
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ASMPH Scholar requirement to find supportfor 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'tgive up 2 3 4 Willing to
give up NA
Your boyfriend/girlfriend?
Your weekends?
Your co-curriculars or orgs ornon-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
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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
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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:
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39. SOFT OR HARD COPIES OF PICTURES OF CARS, HOMES, DORM, ETC (label each clearly)
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I/we hereby certify that all information written in this application is complete and accurate and we are hereby authorized to verify the same.
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
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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
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APPLICANT’S FINANCIAL AUTHORIZATION FORM 2015 – 2016
APPLICANT 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
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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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