APPLICATION FOR ADMISSION SY 20__ - 20__
Application no.: __________________________
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 ________________________________________________________________
Recent
2 x 2
Photo of
Applicant
Photo Guidelines:
Red Background
Colored
Full face, front view
Attire: collared shirt with sleeves
Taken within the past 6 months
Digitally-altered photos are not
accepted
PERSONAL INFORMATION
. Permanent Address
. Mailing Address
Street No.
Street No.
(If not the same as the permanent
address)
(
. Telephone Numbers
Residence
(MM/DD/YEAR)
. Citizenship
. Civil Status
. If married, name of
spouse
Subdivision/Barangay
City/Municipality
Province
Country
ZIPcode
Street
Subdivision/Barangay
City/Municipality
Province
Country
ZIPcode
Office
Area Code
Fax
. E-mail Address
. Date of Birth
Street
Mobile No.
Area Code
. Gender
[ ] Filipino
[ ] Single
. Age
Area Code
Area Code
[ ] Male
[ ] Female
. Place of Birth
[ ] Others, pls. specify
[ ] Married
[ ] Separated
[ ] Widowed
. Religion
. Blood Type
Mobile No.
Contact No.
Last Name
First Name
Area Code
Middle Name
FAMILY INFORMATION
. Fathers Name
Living
Deceased
If College Graduate, from what school? _____________________________________________
Year Graduated _________________ Degree _______________________________________
If employed, name of company/employer ____________________________________________
. Mothers Name
. Guardians Name /
Person to contact in case
of emergency
Living
Deceased
If College Graduate, from what school? _____________________________________________
Year Graduated _________________ Degree _______________________________________
If employed, name of company/employer ____________________________________________
Relation
Contact Number
Name
(
)
Last Name
First Name
Middle Name
Area Code
PLEASE DO NOT WRITE BELOW THIS LINE FOR ADMISSIONS OFFICE ONLY
OFFICIAL RECEIPT NO.: _______________
AMOUNT PAID:
_______________
GWA/QPI: ______________ / _________ ___
NMAT PERCENTILE RANK: ________________
LEGAL NAME
______________________________________________________________________________
(Married Name, if applicable)
Last Name
First Name
. Have you taken the NMAT?
[ ] Yes
If yes, list all exam dates and results below
Date
Standard Score
(MM/DD/YEAR)
Middle Name
[ ] No
Percentile Rank
Testing Center
. SIBLINGS EDUCATIONAL ATTAINMENT (eldest to youngest)
Name
Name
School last attended
Year Level
Course
Graduated
. Do you have any relatives who have attended or are attending Ateneo de Manila?
Relation
Level/Year & Course
Graduated
ACADEMIC INFORMATION
. SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)
Elementary
School
Address
High School
Address
College
Levels Attended
Gr. _____ To _____ __
Period Covered
Yr._____ To Yr.______
Levels Attended
Yr. _____ To Yr._____
Period Covered
Yr. _____ To Yr._____
Degree
Address
Post Graduate
Period Covered
Yr. _____ To Yr._____
Degree
(Including other
College of Medicine)
Address
Period Covered
Yr. _____ To Yr. _____
LEGAL NAME
(Married Name, if applicable)
______________________________________________________________________________
Last Name
First Name
Middle Name
. 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.
Are you graduating with Honors? No
Yes, I graduated/expect to graduate: Summa Cum Laude Magna Cum Laude
Cum Laude
Honorable Mention
. Were you ever dismissed, suspended or placed on probation?
Yes, (Please specify dates, offenses, penalties) _____________________________________________________________
No
EXTRA-CURRICULAR ACTIVITIES
. List your college extra-curricular activities, including positions held or special responsibilities and year. (e. Dramatics
1,2,3,4; Class Secretary 2,4; Basketball Varsity 1,3)
If you are a member of your schools varsity team, what is your skill level (please check):
Average
High
Superior
. List your community and / or church activities.
. Other work experience after graduation from College
Position
Company and Address
Date
OTHER INFORMATION
. Physical Fitness. List any physical defects 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. Yes No
LEGAL NAME
(Married Name, if applicable)
______________________________________________________________________________
Last Name
First Name
Middle Name
. Name the schools to which you have applied or intend to apply, local or foreign including ASMPH.
Priority
Name of School
1st
2nd
3rd
4th
5th
. Give the names of the persons recommending you. NOTE: One (1) recommendation letter must come from each of the following: the
Dean/College Secretary of your school and your Department Chair. In the absence of one, a senior a recommendation letter from a Senior
Professor will be accepted.
1) Dean / College Secretarys Name
2)
Department Chairs Name
3)
Others: Please write Name:
. Financial Aid / Scholarship.
Are you applying for Financial Aid / Scholarship?
[ ] Yes,
Please attach your accomplished Financial Aid form and requirements. Application form may be downloaded from the ASMPH website
[ ] No
PERSONAL ESSAY
. In order for the Admission Committee and Scholarship Committee to get to know you better, write an essay about what
is the role of the doctor as a professional in todays world? (Guidelines: 3 pages short bond paper, double-spaced, Times
New Roman font, 12pt.)
APPLICATION FOR ADMISSION
I hereby certify that all information written in this application is complete and accurate. I agree
if accepted as a student that my admission, matriculation, and graduation are subject to the rules and
regulations of the Ateneo de Manila University.
______________________________________________________
Applicants Signature
Date
______________________________________________________
Parents or Guardians Signature
Date
Do not write below this line.
