How to Fill-up the ASAL and Suretyship Agreement
1. Download the ASAL Form and Reply Slip from cm website and print 4 copies in legalsize.
2. Kindly read the Acceptance to Serve and Assumption of Liability (ASAL) and theSuretyship
Agreement.
3. Fill up (print legibly) ALL the blanks with the information requested in the ASAL (3pages), Suretyship Agreement (2 pages) and Reply Slip.
4. The student and her/his parents MUST sign on the designated blank spaces on page 3of theASAL.
5. In the Acknowledgement portion on page 3, the CTC Nos.(Community Tax Certificate)arethose of the following: (Please attach photocopies of CTC)a) Applicantb) Both parents/signatories
6.
The relatives or friends of legal age may serve as witnesses in the ASAL and in theSuretyship Agreement. The witnesses must sign over printed name andinclude theiraddress on the designated blank and attach photocopy of IDs.
7 For the Suretyship Agreement, the Surety must be either of the following, provided they
aregainfully employed/ has properties;a) Either of student’s parentsb) If the student is married, her/his spouse who is gainfully employed.
c) Legal Guardian who is gainfully employed
8 In the acknowledgement portion, fill up the Government issued ID of the Surety (bothparents) or the Spouse of the applicant(if married). (Please attach photocopy ofIDs)
9Submit four (4) copies in legal size, together with the accomplished Reply Slip.
The
signatures of UP Manila Chancellor and UP College of Medicine Dean will betaken caredof by the Admission Office.
10
If admitted, please pay Php 100.00 for the notarial fee.

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UNIVERSITY OF THE PHILIPPINESCOLLEGE OF MEDICINEPedro Gil St., Ermita, Manila
ACCEPTANCE TO SERVE AND ASSUMPTION OF LIABILITY(ASAL) AGREEMENT(UPCM Regionalization Program)This Acceptance to Serve and Assumption of Liability Agreement (“ASALAgreement”) made and executed thisday ofin, Philippines by and between:, Filipino, of legal age,(full name of student)
single/ married to, with residence and postal address(full name of spouse)at, hereinafter(complete address)
referred to as “Student”;- and University of the Philippines, the national university of the Republic of thePhilippines, created and organized under Act No. 1870 and Republic act No.
9500, represented by DR. MICHAEL L. TEE, MD, MHPEd, MBA, Chancellorof the University of the Philippines Manila, representing the U.P. College ofMedicine, hereinafter referred to as “UPCM”;
WITNESSETH: That
WHEREAS, the Regionalization Program of the UPCM hereinafter referred to as(the “Program”) strives to ensure excellence and leadership in community-oriented medical
education, research and service, using the primary health care approach, intended
especially for the underserved;
WHEREAS, the Student has applied to the Program and is aware of therequirements of the said program, and for this purpose, the Handbook on the UPCM
Return Service Obligation Program and the Regionalization Program is hereto attached asAnnex “A” the same to form an integral part hereof;
WHEREAS, this agreement becomes effective only upon acceptance of the student
to the College of Medicine;
WHEREAS, in consideration of her/his admission to the Program and her/his being
covered/under the above mentioned Agreement and considering her/his availment of statesubsidy in her/his tuition fees, the student is required by UPCM to render health careservices in her/his regionor other underserved(specific province)
regions of the Philippines as defined by the Department of Health, immediately after her/ hisgraduation;
NOW, THEREFORE, in consideration of the foregoing premises, the Parties agree
as follows:
Article I. Obligations of the Student
The Student, having been accepted into the Regionalization Program (the“Program”) of the UPCM and covered by/under the ASAL Agreement shall:

1. Faithfully adhere to the Vision-Mission of the UPCM specifically the ideals andrequirements of the Program;
2. Abide by the prescribed course or instruction unless sooner separated ordismissed by competent authority for failure to cope with the academic and/or
disciplinary standards, rules and regulations;
3. Obtain a Philippine Medical License within 2 years from the date of her/hisPage 2 of 3

UPCM graduation;
4. Render health care services in his/her province
or in anotherprovince within the same region, or if this is not possible for any valid reason, in
an underserved region of the Philippines classified as such by the Department ofHealth.
5. The return service shall be rendered immediately after graduation, or after
residency training program as the case may be, for a minimum of five (5) years
within ten (10) years from the date of graduation. However, for subspecialty
fellowship programs that would require additional years of training which will
mean a violation of the 5-in-10 year rule for the return service, a formal request
for such training must be submitted by the graduate to the RP Committee. The
fellowship training will be undertaken only in the country. The committee, afterdue deliberation, will then make its final recommendation to the Dean for theapproval/disapproval of the request for extension of the timeframe for the returnservice.
6. For RP graduates who were admitted to the MD-PhD program, the 5-in-10 year
rule of the return service may commence after the completion of the PhD
program by the graduate or after completion of the graduates’ obligation to thesponsoring agency.
7. Submit on or before June 30 and December 31 of every year until completion ofthe Return Service Obligation, beginning the year he/she graduated from UPCM,
a report of her/his health care activities and services for that year, specifying thefollowing minimum required information:
a.
b.
c.
d.
e.
f.

Exact location and address where he/she is currently working
Complete name of the institution where he/she is working
The area or areas served
Brief description of the service work being performed
Good practices encountered including insights & analysis
Problems and challenges encountered including proposed strategies toaddress these concernsg. Service goals and plans for the next 6 months
Article II. Penalty for Breach
1. The Student acknowledges and agrees that before the completion of her/hisobligations under Article I of this Agreement and such other obligations as may fromtime to time be imposed by concerned University officials in the implementation of said
Agreement, her/his transcripts of grades and/or diploma shall bear the statement“Subject to compliance with the Return Service Agreement. Valid for employment within
the Philippines only.”
2. In addition, the Student shall be held liable for breach of contract jointly andseverally with her/his parents or guardians, and guarantor/surety as provided for in theSuretyship Agreement hereto attached as Annex “B”, and reimburse to UPCM apayback equivalent to double the cost of medical education up to the year levelcompleted or currently in.
Article III. Free and Harmless Clause
Any loss and/or damage caused by the Student to any person as a result of her/his performance of health care services as required under this ASAL Agreement shall be
the sole and exclusive liability and responsibility of the Student. In this connection, theStudent holds UPCM free and harmless from all claims, proceedings, damages, costs,charges and expenses whatsoever arising out of or as a result of such loss and/ordamage.
Article IV. Alternative Dispute Resolution
In case of a dispute between the Parties, arising from the breach by the Studentof her/his obligations under this ASAL Agreement, they hereby agree to freely andvoluntarily submit themselves to the necessary consultation and negotiation for
purposes of amicably settling their dispute through the Appeals Committee. Should thePage 3 of 3

Parties fail to reach an amicable settlement, any dispute or controversy arising from thisAgreement shall be submitted to arbitration, in accordance with law (RA 9285). Finally,
the Parties agree that should their dispute reach the courts of law, the competent courtsof Manila shall have exclusive jurisdiction over the same.
IN WITNESS WHEREOF, the Parties sign this ASAL Agreement together withthe parent(s)/guardian(s) of the Student, thisday ofat, Philippines.

Name and Signature of Student

MICHAEL L. TEE, MD, MHPEd, MBA___Chancellor, UP Manila

Name and Signature of Mother

Name and Signature of Father

Signed in the presence of:
CHARLOTTE M. CHIONG, MD, PhD
Dean, UPCM

Signature over printed nameof witness

ACKNOWLEDGEMENT
Republic of the Philippines), Metro Manila) s. s.
BEFORE ME, thisappeared:
Name

day ofCTC No.

, in, personallyDate/Place Issued

known to me and to me known to be the same persons who executed the foregoing
instrument and they acknowledged to me that the same is their free and voluntary act
and deed as well as that of the institution represented.
This instrument refers to an Acceptance to Serve and Assumption of Liability(ASAL) Agreement that consists of three (3) pages, including the page whereon theacknowledgment is written.
WITNESS MY HAND AND NOTARIAL SEAL, on the date and place abovewritten.
Doc. No.
;
Page No.
;
Book No.
;
Series of 202_.
AY 2016/RP

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SURETYSHIP AGREEMENTFOR UPCM ASAL AGREEMENT
This Agreement executed atbyon(place), Filipino, of legal age,(date)
single/ married to(full name of surety),with residence and postal address at(full name of spouse), hereinafter referred to as “Surety”, in favor(complete address)of the University of the Philippines Manila College of Medicine, with principal
office at Pedro Gil St., Ermita, Manila, hereinafter referred to as “UPCM”;
WHEREAS,(hereinafter referred to as(full name of student)“Principal”), a student of the UPCM Regionalization Program, executed theattached Acceptance to Serve and Assumption Liability Agreement (“ASALAgreement”) with UPCM on, to which(date of ASAL)
this Surety Agreement is attached to as ANNEX “B”;
WHEREAS, UPCM requires that the due and faithful performance of theprovisions of the said ASAL Agreement be underwritten by a Surety;
NOW, THEREFORE, for and in consideration of the foregoing, theundersigned Surety, jointly and severally with the Principal, hereby guaranteeand warrant to UPCM that the Principal shall comply with and perform all thestipulations contained in the ASAL Agreement, and that if for any reason thePrincipal fails to comply therewith, the Surety binds himself jointly and severallywith the Principal:“To reimburse the UPCM twice the full of such amount/s as
may have been defrayed for the Principal’s tuition, government
subsidy and scholarship, and all other expenses incurred by
the UPCM, with interest at the prevailing legal rate at the timeof the breach of the aforesaid ASAL Agreement”.
The liability of the Surety under this Agreement shall be solidary, direct
and immediate and not contingent upon the enforcement by UPCM of whatever
remedies it may have against the Principal, and the Surety shall at anytime on
demand, pay to the UPCM whatever amount is owing from the Principal to theUPCM to the extent stated above.
This instrument is intended to be a complete and free indemnity to UPCM
for any indebtedness or liability of the Principal arising from the ASAL
Agreement. It shall be valid and binding without further notice to the Surety, until
the Principal has complied with all her/his obligations under the said ASAL
Agreement.

1

IN WITNESS WHEREOF, the Surety has caused its authorized
representative to set her/his hand thisday of, 201 , in.

Name & Signature of SURETY

Name & Signature of SPOUSEof SURETY (if married)

Signed in the presence of:

Signature over printed name of witness

Signature over printed name of witness

ACKNOWLEDGEMENT
Republic of the Philippines), Metro Manila) s.s

BEFORE ME, thispersonally appeared:
Name

day ofGovt. Issued ID, in,

Issuance Details

known to me and to me known to be the same persons who executed theforegoing instrument and they acknowledged to me that the same is their freeand voluntary act and deed as well as that of the corporation herein represented.
This instrument refers to as Suretyship Agreement for UPCM
Regionalization Program consists of two (2) pages, including the page whereon
the acknowledgement is written.
WITNESS MY HAND SEAL on the date and at the place first writtenabove.

Doc. No.
Page No.
Book No.
Series of 202;;;.

AY2016/RP2