F. FCPS-I 1 (f.babar) 13611

Price Rs. 50/=

AAPPPPLLIICCAATTIIOONN FFOORRMMFCPS - I EXAMINATION

NOVEMBER 16, 2011

FRESH C

ANDIDATE

ALL ENTRIES TO BE MADE IN INK AND IN BLOCK LETTERS

Name (As given in MBBS/BDS Degree)

PRESENT MAILING ADDRESS (Residential)

Name of Father / Husband

Date of Birth

- -

D M Y

AREA CODE NO.

Marital Status Married ❑ Single ❑

Nationality Sex Male ❑ Female ❑

City Country

C.N.I.C

Tel (Res)

CODE NO.Cell Email

PERMANENT ADDRESS (If different from above)

--

--

AREA CODE NO.Tel (Res) AREA CODE NO.Office --

Coloured, recent & alike

Passport Size Photograph( 5 x 6 cm)Pasted &

attested on front

City Country

7th Central Street, D.H.A. Phase II,Karachi-75500 (Pakistan)Tel: 99207100-09; Fax: 99207120, 35881444UAN: 111-606-606E-mail: examinations@cpsp.edu.pkWeb-site: www.cpsp.edu.pk

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(If you do not have a telephone at your residence & office, please give a telephone number of your relative/friend throughwhom messages could be conveyed to you)

--

AREA CODE NO.Office --

FFCCPPSS--IIWWEEBBCCOOPPYY

F. FCPS-I 2 (f.babar) 13611 Page -2

EXPERIENCE SPECIALITY NAME OF INSTITUTION DATE

Supported by a certificate clearly indicating that one year house job has been completed from PMDC approvedinstitution, at least two months before the date of examination.

EXPERIENCE SINCE GRADUATION

House Job

Any Other

From ToD M Y D M Y

D M Y D M Y

No/Date Bank Branch City

EXAMINATION FEE

Challan United Bank Ltd.

Bank Draft

Pay Order

Qualification & Name of Institution No & DateDate of Graduation of PMDC Registration

PROFESSIONAL QUALIFICATIONS

CHOOSE & FILL IN ONE SPECIALITY UNDER CHOSENSPECIALITY OUT OF THE FOLLOWING IN BLOCK LETTERS

1. Anaesthesia

2. Dentistry

3. Diagnostic Radiology

4. Medicine & Allied

5. Obstetrics & Gynaecology

6. Ophthalmology

7. Otorhinolaryngology (ENT)

8. Pathology

9. Psychiatry

10.Surgery and Allied

11. Community Medicine

CHOOSE & FILL IN ONE CENTRE UNDER CHOSEN CENTRE FOREXAMINATION OUT OF THE FOLLOWING IN BLOCK LETTERS

1. Abbottabad

2. Bahawalpur

3. Faisalabad

4. Hyderabad

5. Islamabad

6. Karachi

7. Lahore

8. Larkana

9. Multan

10. Nawabshah

11. Peshawar

12. Quetta

13. Rawalpindi

CHOSEN CENTRE

CHOSEN SPECIALITY

F. FCPS-I 3 (f.babar) 13611 Page -3

Name, address & telephone Nos. of attester of documents (The attester should be one of the followings:)

i) Fellow of the College of Physicians & Surgeons Pakistan with his Fellowship Number.ii) Principal/Professor of PMDC approved Medical Colleges / Postgraduate Medical Institutions

Medical Superintendent / Head of the Medical Institution.

1.

2.

DECLARATION

I, Dr.

S/o D/o W/o

DATE:

SIGNATURE OF CANDIDATE

Coloured, recent & alike

PHOTOGRAPHPassport Size

( 5 x 6 cms)ATTESTED

on back indicating name of

candidate in CAPITAL LETTERS

& stapled

FOR OFFICE USE ONLY

D M Y

DATEReceipt No.

Processed by

Name of applicant

Checked by

Rechecked by

do hereby declare that information given above is correct to the best of my knowledge. Incorrectinformation may lead to cancelation of enrollment /admission /results and disciplinary action.

F. FCPS-I 4 (f.babar) 13611 Page - 4

I N S T R U C T I O N S

The eligibility of the candidates shall be ascertained on the basis of certificates of the

requirements submitted with this application form which will be treated as final. No further

correspondence shall be made in this regard.

Attested Photocopies of following documents to be enclosed

i. MBBS /BDS Degree

ii. Valid Pakistan Medical & Dental Council Registration Certificate. In case of foreign

candidates, valid registration certificate of their own country’s medical council, equated

by PMDC.

iii. Certificate of One Year House Job from institutions recognized by PMDC, duly counter

signed by the head of institution. House Job must have been completed Two months before

the date of examination i.e. by September 16, 2011 for November 16, 2011 examination.

Evidence of having paid examination fee (challan form or original Bank Draft / Pay

Order/Bank Receipts).

Four recent & alike Photographs, one to be pasted in the box on the first page of each form

(application and enrolment) and got attested on front. Remaining photograph to be attested on

the reverse side and stapled (not pasted) in the box provided. This photograph should also bear

the name of the candidate written on the reverse side in capital letters.

Attested photocopy of Computerised National Identity Card.5

4

3

2

1

LIST OF DOCUMENTS REQUIRED TO BE ENCLOSED WITH THE APPLICATION FORM

Theory examination is conducted at Karachi, Hyderabad, Quetta, Bahawalpur, Multan, Lahore,Faisalabad, Rawalpindi, Islamabad, Peshawar, Larkana, Abbottabad, Nawabshah, Kathmandu (Nepal)and Saudia Arabia (Riyadh).

The College can hold examination in any of the listed cities of the country depending on the numberof candidates and logistic facilities available in a city irrespective of the choice given in the Boxabove.