financial aid application form - ateneo de manila … fa...certification indicating amount of...
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Ateneo de Manila University School of Medicine and Public Health
Financial Aid Application Form – NON OFW Income
NEW APPLICATIONS ONLY THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME
If some or all of your income is from outside the Philippines, please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”
SY 2014 – 2015
ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED.
THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED
FOR ONLY ONE YEAR, RENEWABLE ANNUALLY.
ANY FINANCIAL AID GRANT =
TUITION & FEES COST – FAMILY CONTRIBUTION.
ASMPH EXPECTS THAT FAMILIES WILL CARRY
AS MUCH OF THE BURDEN AS POSSIBLE.
INSTRUCTIONS
1. This application should be accomplished by the APPLICANT & PARENTS together. ALL
QUESTIONS must be answered carefully and completely. Forms that are not completely filled
out will not be processed.
2. Submit the following by the deadline:
a. FA APPLICATION FORM;
b. APPLICANT’S DETAILED PERSONAL NEEDS ESSAY
WHY YOU NEED HELP with details of the FAMILY’S FINANCIAL SITUATION.
This ESSAY MUST BE COMPLETE AND TRUTHFUL.
c. Photos of:
i. PERMANENT and LOCAL residences (whether owned, borrowed, loaned, or
rented) where you stay showing the OUTSIDE (FRONT, BACK, SIDES) of the
HOUSE or apartment as well as the ROOMS INSIDE.
ii. EACH VEHICLE (whether owned, borrowed, loaned, or rented) showing the
FRONT and SIDE of EACH VEHICLE
iii. EACH PROPERTY, LOT, or HOUSE (other than PERMANENT or LOCAL
RESIDENCES) SHOWING the OUTSIDE (FRONT, BACK, SIDES) of the
HOUSE or PROPERTY as well as the ROOMS INSIDE THE HOUSE.
3. To be submited BEFORE THE INTERVIEW:
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a. Certificate of Employment & Compensation (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 letter;
4. All information will be kept STRICTLY confidential.
5. Applying for Financial Aid does NOT affect ADMISSION to ASMPH.
6. Place your documents IN A SEALED LEGAL SIZE BROWN ENVELOPE LABELED WITH
YOUR NAME (LAST, FIRST, MI) IN THE UPPER LEFT CORNER and
Submit these documents to:
Christopher K. Peabody, Advancement Officer,
ASMPH Financial Aid Committee
ASMPH Building, Ortigas Avenue 1604, Pasig City
DOCUMENTS CHECKLIST:
THIS Financial Aid Application
Personal Needs Essay written by the Aplicant
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 2013
Legal size brown envelope
Applicant’s Name in TOP LEFT corner as
“Last name, first name, MI”
Last name, first, MI
Christopher Peabody
ASMPPH Financial Aid Com
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 3 of 21
Ateneo de Manila University SY 2014 - 2015
School of Medicine and Public Health
Financial Aid Application Form – NON OFW Income
THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME
If some or all of your income is from outside the Philippines, “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”
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 ______________
NMAT ________% taken when _______ GPA ________* where A = [ ]4 [ ]5 [ ]1 *latest semester
1. SCHOLARSHIP REQUEST
₂ PERCENTAGE GRANT REQUESTED
100% 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.)
Street No. Street Subdivision/Barangay City/Municipality
Province Country ZIP code
Recent 2” x 2”
Photo of Applicant
(PLEASE WRITE YOUR NAME AT THE BACK)
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 4 of 21
₉LOCAL 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
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 INFORMATION
FATHER ₂₂PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED
23Is he the Primary Wage earner of Family [ ] YES [ ] NO 24Age
₂₅Father’s Name
Last Name First Name Middle Name
₂₆Father’s 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
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 ______________
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 5 of 21
[ ] Regular or [ ] Contractual Annual gross salary in the firm ___________________
If self-employed, nature of work ______________________________________________
Do you [ ] own or [ ] share ownership of this business?
If Father is primary wage earner AND currently UNEMPLOYED,
please attach a separate letter explaining
when last employed and reason for unemployment
MOTHER ₃₁PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED
₃₂Is she the Primary Wage earner of Family [ ] YES [ ] NO ₃₃Age
₃₄Mother’s Name
Last Name First Name Middle Name
₃₅Mother’s 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
Mobile No. 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
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 6 of 21
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
Mobile No. 2
( ) Area Code
₃₇Guardian’s e-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 ______________________________________________
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 needed
NAME Age School last attended Year Level Course Graduated
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 7 of 21
4. APPLICANT ACADEMIC INFORMATION ₅₄SCHOOLS 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 (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
₅₆Are you graduating with Honors?
[ ] No [ ] Yes, I graduated/expect to graduate: [ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention
5. EXTRA-CURRICULAR ACTIVITIES
₅₇List your college extra-curricular activities, including positions held or special responsibilities and year. (e. Dramatics – 1,2,3,4; Class Secretary – 2,4; Basketball Varsity – 1,3) Attach a separate sheet if needed
₅₈List your community and / or church activities. Attach a separate sheet if needed
₅₉Other work experience after graduation from College - Attach a separate sheet if needed Position Company and Address Date
₆₀Were you ever dismissed, suspended or placed on probation? [ ] Yes [ ] No If Yes, specify dates, offenses, penalties ______________________________________________
Please attach a separate sheet explaining the circumstances
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 8 of 21
6. FAMILY GROSS INCOME (Philippine based only) If some or all of your income is from outside the Philippines,
please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”
Contributed Annual Income given SAVING & Other Income: Father Money Market Placements
Mother Market Value of Securities
Brothers Bank Deposits
Sisters Current
SUB-TOTAL from FAMILY Savings
For the following, ALSO fill out Section 23 Time Deposit
Support from Grandparents Stocks
Support from Uncles/Aunts Foreign Currency Deposit
Support from Other relatives Interest earned on all above
Support from Friends Other (specify): ____________________
From Relatives/friends overseas Other (specify): ____________________
Other (specify): ______________________ Other (specify): ____________________
SUB-TOTAL from RELATIVES/FRIENDS SUB-TOTAL FOR SAVINGS, ETC
PROFITS EARNED LOANS FOR LIVING EXPENSES Profit on Business Borrowed from family
Profit/Rentals on Lands Borrowed from Friends
Rentals on Residence/Buildings Borrowed from banks or others
Commissions Other Loans(specify): _______________
Retirement Benefits/Pensions
SUB-TOTAL for PROFITS EARNED SUB-TOTAL for LOANS
Other Income (specify):
_________________________________ _________________________________
_________________________________ _________________________________
_________________________________ _________________________________
SUB-TOTAL for OTHER INCOME
TOTAL GROSS ANNUAL INCOME =
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 9 of 21
7. FAMILY GROSS EXPENSES (Philippine based only) If some or all of your income is from outside the Philippines,
please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”
If the applicant does not live with family, please DO NOT ADD APPLICANT EXPENSES TO
FAMILY EXPENSES BELOW. Instead, please ANSWER DORM SECTION below.
BASIC MONTHLY FAMILY EXPENSES ACTUALLY PAID UNPAID or OWED
Food/Grocery
House Rent/Amortization
Electricity
Water LPG
Telephone (landline)
DSL/ Broadband
Cable TV
Cell phone
Clothing, Uniforms Transportation (parents)
School Bus or car pool
Salaries of helpers, housekeeper, driver, others
Medicines (if total is greater than P500 per month, please fill out Section 25)
SUB-TOTAL for BASIC MONTHLY FAMILY EXPENSES
MONTHLY CREDIT EXPENSES ACTUALLY PAID UNPAID or OWED
Monthly Loan payments (please identify to whom/why paid)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for MONTHLY LOAN PAYMENTS
Monthly Credit Card payments
____________________________________________
____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for MONTHLY CREDIT CARD PAYMENTS
Other Monthly Payments (please identify to whom/why paid)
____________________________________________
____________________________________________
____________________________________________
SUB-TOTAL for OTHER MONTHLY PAYMENTS
BASIC MONTHLY EXPENSES SUBTOTAL
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 10 of 21
DORM SECTION: IF YOU DO NOT LIVE WITH YOUR FAMILY (i.e. Dorm, shared apartment, room or coop, etc.),
please ANSWER BELOW: Rent per month paid by applicant
Electricity/water/gas/condo dues paid by applicant
Food purchased whether in school of at dorm/condo
Transportation costs to & from dorm/condo/hospital/LEC
Transportation costs to & from parents
Xeroxing, etc.
Internet in dorm or broadband
Other personal needs (specify): ____________________________
____________________________________________
____________________________________________
Medical expenses for the applicant (if total is greater than P500 per month, please fill out Section 25)
MONTHLY SUB-TOTAL for DORM EXPENSES
TOTAL MONTHLY FAMILY EXPENSES
(BASIC + DORM)
TOTAL MONTHLY FAMILY EXPENSES X 12 =
TOTAL MONTHLY EXPENSES PER YEAR
8. ANNUAL FAMILY EXPENSES (Philippines based income)
ANNUAL FAMILY EXPENSES ACTUALLY PAID UNPAID or OWED
School Tuition & Fees (please give details in # 11 below)
School Supplies/Books (please give details in # 11 below)
Withholding Tax (per year)
Insurance Plans (compute per year)
SSS/GSIS/Pag-Ibig/PhilHealth
Other ANNUAL expenses (specify): ________________________
_________________________
SUB-TOTAL for ANNUAL FAMILY EXPENSES
TOTAL FAMILY EXPENSES =
(MONTHLY X 12) + (ANNUAL)
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 11 of 21
9. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET (Philippines based income)
ACTUALLY PAID UNPAID or
OWED
TOTAL GROSS ANNUAL INCOME + +
TOTAL ANNUAL EXPENSES/DEBT -- --
SURPLUS/ LOSS FOR THE YEAR
NOTE IF SURPLUS/LOSS FOR THE YEAR IS SIGNIFICANTLY NEGATIVE (I.E. YOUR FAMILY SPENDS MORE THAN 10% THAN IT EARNS)
YOU ARE REQUIRED TO ATTACH A SPECIAL LETTER FROM YOUR PARENTS EXPLAINING
HOW THEY ARE ABLE TO PAY THIS. DO NOT SKIP THIS STEP
10) REQUIRED ADDITIONAL INFORMATION ABOUT ANNUAL PAID INCOME OF APPLICANT
THIS INCLUDES SUPPORT RECEIVED BY THE APPLICANT from PART/FULL TIME WORK, RELATIVES, FRIENDS, SCHOLARSHIPSand other NON FAMILY SOURCES
Name of employer,
relative, friends, scholarship or
donor
Years receiving help
For PAID WORK, what type of work (leave
blank if no work)
For PAID WORK, hours per week
or month
For Relatives, friends and
Donors, what is Relationship to
APPLICANT
Attach a separate sheet if needed
11. TUITION & FEES for Sibling’s CURRENTLY IN SCHOOL or ABOUT TO GO TO SCHOOL
Applicant and Siblings NAMES
Age School Grade/
Year Level
Yearly Tuition & Fees of
school
Yearly School Supplies/
Books
Amount covered by
parents
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 12 of 21
12. 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
Item Name/brand/model #
If this is NOT
exclusively for you,
who else uses it
Acquired
When
Approximate
Acquisition
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
Car (fill out section 19)
Jewelry/watch
(specify):
Braces
Other (specify):
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 13 of 21
Other (specify):
Other (specify):
Attach a separate sheet if needed
13. FAMILY HOUSEHOLD POSSESSIONS DECLARATION
Please list all possessions worth more than P2,500 that your FAMILY uses regularly even if your
family does not own them. Be VERY complete & clear - these details are subject to verification Leave any item blank if not applicable
Brand(s) & Model(s) Acquired When Cost
TV sets
VHS/VCD/DVD
Stereo/Karaoke
Cellular phones
Laptop
PC
Printer
Refrigerators/ Freezers
Microwave/Oven
Washing Machine/Dryer
Air conditioner
Piano/organ
Other (specify):
Other (specify):
Other (specify):
Attach a separate sheet if needed
14. PERSONAL & FAMILY MEMBERSHIPS
Please list ALL MEMBERSHIPS costing worth more than P1,000 per month that you or your
FAMILY have or use even if not paid for by you or your family. Memberships can be in gym, golf
club, sports club, etc. Be VERY complete & clear - these details are subject to verification.
Membership For what purpose Acquired When Cost
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 14 of 21
15. PERSONAL BANK ACCOUNTS
Please list ALL YOUR BANK ACCOUNTS that you USE whether they are yours or not. Be VERY complete & clear - these details may be subject to verification.
Bank
Type of account
(savings/checking/atm) Acquired When Current balance
Attach a separate sheet if needed
16. FAMILY BANK ACCOUNTS
Please 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
Attach a separate sheet if needed
17. PERSONAL CREDIT OR DEBIT CARDS
Please list ALL CREDIT or DEBIT CARDS that YOU USE whether you pay for it or not. Be VERY complete & clear - these details are subject to verification.
Credit or Debit Card Who Pays the Bill Acquired When Current Credit Limit
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 15 of 21
18. FAMILY CREDIT OR DEBIT CARDS
Please list ALL CREDIT or DEBIT CARDS that YOUR FAMILY USES whether they pay for it or not. Be VERY complete & clear - these details are subject to verification.
Credit or Debit Card Who uses the card Who Pays the Bill Acquired When Current Credit Limit
Attach a separate sheet if needed
19. DOMESTIC OR INTERNATIONAL TRAVEL BY YOU PERSONALLY
OR YOUR IMMEDIATE FAMILY DURING THE PAST 3 YEARS
This includes ALL TRIPS to/from your permanent residence or to/from ASMPH or your college if greater than 200 km. Leave any item blank if not applicable.
For ASMPH students, please include travel required by your summer internship. Be VERY complete & clear - these details are subject to verification
Person(s) traveling &
relationship to you:
Purpose of trip
(i.e. vacation,
emergency, etc.)
Dates of
trip Destination(s)
By Ship
Airline,
Bus,
or Car
Estimated
Cost of trip
Who paid
for the
trip?
Attach a separate sheet if needed
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 16 of 21
20. PERSONAL & FAMILY VEHICLE DECLARATION
Please list ALL VEHICLES THAT YOU OR YOUR FAMILY USES REGULARLY even if your family does not own them.
Be VERY complete & clear - these details are subject to verification
PLEASE ATTACH RECENT PHOTOGRAPHS OF EACH VEHICLE SHOWING THE FRONT and SIDE of EACH VEHICLE
Make/Yr Model When Purchased Amt of Purchase Amt Paid For
Company/
Family Owned
Attach a separate sheet if needed
21. FAMILY PPROPERTIES OWNED OR USED (RESIDENTIAL, COMMERCIAL, ETC.)
PLEASE ATTACH RECENT PHOTOGRAPHS of EACH PROPERTY or HOUSE SHOWING the OUTSIDE (FRONT,
BACK, SIDES) of the HOUSE or PROPERTY as well as the ROOMS INSIDE THE HOUSE.
Description
and/or use Location Size
Acquired
When
Value at
Acquisition
Present
Market Value
Yearly Net
Income
Attach a separate sheet if needed
22. SIBLINGS NO LONGER IN SCHOOL
Name Age
Civil
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.
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 17 of 21
23. SERIOUS ACUTE OR CHRONIC ILLNESSES
IF YOUR MONTHLY MEDICAL OR MEDICINE BILLS ARE GREATER THAN P500 PER MONTH, please detail those serious medical, surgical, physical or mental disabilities, or mental illnesses which cause your family to spend.
Name Age Re
lati
on
ship
to
yo
u
Diagnosis #
of
tim
es
ho
spit
aliz
ed
Current treatment /medicines
required
Est. annual treatment
cost
ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENT Attach a separate sheet if needed
24. OTHER DEPENDENTS LIVING IN YOUR HOUSE
Name Age
Civil
Status
Relation-
ship 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.
25. 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-
ship to you
Who
receives
help
Help 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
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 18 of 21
26. SIBLINGS ON ATENEO SCHOLARSHIPS & EDUCATIONAL PLANS Are any of your siblings presently on scholarship in Ateneo: Yes No
Please check if any of your siblings presently on scholarship in Ateneo:
Merit/Athletic Who/how much? ________________________________
Financial aid Who/how much? __________________________________
In which school(s): Grade School High School Loyola Schools
Please list siblings and type of scholarship of who received scholarships in the past from the Ateneo de Manila?
Do not list yourself.
______________________________________
______________________________________
______________________________________
Are any of your siblings enrolled under an education plan for:
What company?
Grade School High School Loyola Schools
____________________________________________
27. WORKING STUDENT DECLARATION
If you are a working student, how many hours do you work: Per day? Per week?
What days of the week? _______________________________________________
If working regularly interferes with your studying,
what do you plan to do?
________________________________________________
________________________________________________
28. EMIGRATION & OFW DECLARATION Are 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.
__________________________________________________
__________________________________________________
29. YOUR EXPERIENCE WITH MEDICINE
Please answer the following questions as truthfully as possible:
Are you a member of the pre-med org? Yes No
Are you a member of any org which serves poor, sick, or
hospitalized children or adults? Yes No
Have you ever joined a medical mission or helped during any medical procedures? Yes No
Have you visited any medical schools prior to applying to ASMPH? Yes No
Have you ever been confined as a patient in a hospital? Yes No
Are any of your relatives actively working as doctors? Yes No
Have you discussed the life of doctor with a doctor relative or
your doctor or teacher? Yes No
Have you ever spent time with a doctor relative while they practice medicine? Yes No
Have you ever spent time with a doctor or
other health professional as they do their job? Yes No
Have you ever worked in a hospital or health center as volunteer? Yes No
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 19 of 21
On a scale from 1 to 5, please rate HOW HAPPY YOU ARE ABOUT THE FOLLOWING:
Unhappy
Very Happy
1 2 3 4 5
Going to school for 10 or more years
Classes are really difficult.
Being dependent on your family for another 5-10 years
Medical lifestyle with hours that are long
Going to class from early morning to early evening
Studying for hours every day of the week
Loss of independence or carefree college lifestyle
3 year mandatory service requirement for ASMPH scholars
ASMPH Scholar requirement to find support for a new ASMPH scholar within 20 years after ASMPH graduation
Getting through medical school requires giving up many things. On a scale of 1 to 5, please rate HOW WILLING YOU ARE TO GIVE UP THE FOLLOWING:
Your boyfriend/girlfriend? Won't give up 1 2 3 4 5 Willing to give up
Your weekends? Won't give up 1 2 3 4 5 Willing to give up
Your co-curriculars or orgs or
non-worship church activities? Won't give up 1 2 3 4 5 Willing to give up
going to movies Won't give up 1 2 3 4 5 Willing to give up
going to gimmicks or parties Won't give up 1 2 3 4 5 Willing to give up
reading non medical literature Won't give up 1 2 3 4 5 Willing to give up
watching TV or DVDs Won't give up 1 2 3 4 5 Willing to give up
Seeing your family as often? Won't give up 1 2 3 4 5 Willing to give up
On a scale from 1 to 5, please rate the following:
How much do your parents want you to go to medical school?
Against my going
1 2 3 4 5 TOTALLY
determined
How important is it to your parents
that 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 you have doubts about going to medical school?
No doubts 1 2 3 4 5 Frequent doubtful
How would you rate your commitment to finishing medical school?
Unsure if I'll finish)
1 2 3 4 5 Totally
committed
How much you REALLY want to go to medical school?
Will go if accepted
1 2 3 4 5 totally
determined
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 20 of 21
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?
30. OTHER INFORMATION
List any physical problems that should be taken into consideration in planning your program of studies and school activities.
Have you ever been forced to stop schooling for a month or more because of poor health? Give details and dates.
ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 Page 21 of 21
31. PERSONAL NEEDS ESSAY
In order for the Committee on Admission and Aid to understand your needs, write an essay about yourself and your family explaining why you need financial aid. You must be honest and complete. All information you give is confidential and will not
be shared with anyone without your written permission. (Guidelines: 2-3 pages short bond paper, single-spaced, Times New Roman font, and 12 pt.)
32. Persons to Recommend You Please name two persons in your community (excluding relatives) whom the Committee
may get in touch with for possible inquiry. (Do not leave this blank Name Address Contact Numbers
_____________________________________________________________________________
_____________________________________________________________________________
Ateneo de Manila University School of Medicine and Public Health
Financial Aid Application Form
I hereby certify that all information written in this application is complete and accurate and we
are hereby authorized to verify the same.
I understand that misrepresentation of information or withholding of information requested in
this questionnaire will be considered reason for disapproval or cancellation of financial aid.
I agree if accepted as a scholar that my admission, matriculation, and graduation are subject to
the rules and regulations of the Ateneo de Manila University.
________________________________________________________ Applicant’s Signature Date
________________________________________________________ Parent’s or Guardian’s Signature Date
Do not write below this line.