F. MCPS 1 (f.b@b@r) 20511

Price Rs. 50/=

AAPPPPLLIICCAATTIIOONN FFOORRMM

OCTOBER 12, 2011

FRESH CANDID

ATE

ALL ENTRIES TO BE MADE IN INK AND FILL ALL COLUMNS IN BLOCK LETTERS

Coloured, recent & alike

Passport Size Photograph( 3 x 4 cm)Pasted &

attested on front

MM CC PP SS EE XX AA MM II NN AA TT II OO NN

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7th Central Street, D.H.A. Phase II,Karachi-75500 (Pakistan)Tel: 99207100-10Fax: 99207120, 35881444UAN: 111-606-606E-mail: examinations@cpsp.edu.pkWeb-site: w w w . c p s p . e d u . p k

RTMC Registration No

Chosen Speciality for Examination

Chosen Centre of Examination

Name (As per MBBS/BDS Degree)

Name of Father / Husband

SUPERVISOR DETAILS

Name:

Designation & Name of Institution

Supervisor’s RTMC Registration No

WWEEBBCCOOPPYYMMCCPPSS

PMDC Registration No

F. MCPS 2 (f.b@b@r) 20511

Page -2

No/Date Amount Bank Branch

EXAMINATION FEE

Challan United Bank Ltd.

Bank Draft

Pay Order

PRESENT MAILING ADDRESS (Residential Only)

Date of Birth

- -

DD MM YYYY

AREA CODE NO.

Marital Status Married ❑ Single ❑

Nationality Sex Male ❑ Female ❑

Province / Azad Kashmir / FATA / Gilgit / Baltistan (Please Tick (✔) if applicable)

City Country

C.N.I.C

Tel (Res) AREA CODE NO.Office

CODE NO.Cell Email

PERMANENT ADDRESS (If different from above)

--

--

--

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

--

City Country

A candidate who does not appear in the immediately following TOACS / Clinical examination afterpassing theory examination will loose one chance. Only two out of three consecutive chances will beavailable to such candidates.

Theory examination is conducted only at Karachi, Hyderabad, Quetta, Bahawalpur, Multan, Lahore,Faisalabad, Rawalpindi, Islamabad, Peshawar, Larkana, Abbottabad, Nawabshah. The College canhold theory and clinicals examination in one or more cities of the country depending on the number ofcandidates and logistic facilities available in a city irrespective of the choice given in the box above.

★

F. MCPS 3 (f.b@b@r) 20511

Page -3

DECLARATION BY CANDIDATE

I, Dr.

S/o D/o W/o

do solemnly declare that all information provided above are correct.

DD MM YYYY

DATE SIGNATURE OF CANDIDATE

PRESENT EMPLOYMENT STATUS(Tick Mark Appropriate Box)

Employed ❑Self Employed ❑

If employed:

Designation

Name of Institution

Address of Institution

Name of Immediate Supervising Officer

We certify from personal knowledge and repute that

FULL NAME OF CANDIDATE _______________________________________________________

He/she has successfully completed a period of training which complies with the CPSP ExaminationRegulations.Is, as regards character and professional conduct, a fit and proper person to be admitted as memberof the College of Physicians & Surgeons Pakistan.

2

1

CERTIFICATE OF SUPERVISOR / HEAD OF INSTITUTION

SUPERVISOR

Name:Designation: SignatureStamp

HEAD OF INSTITUTION (M.S. , Dean, Assoc. Dean, Commandant, Principal)

Name:Designation: SignatureStamp

INCOMPLETE APPLICATION WILL NOT BE PROCESSED WITHOUT AFFIRMATION OF

SUPERVISOR AND HEAD OF INSTITUTION

F. MCPS 4 (f.b@b@r) 20511

Page -4

FOR OFFICE USE ONLY

DD MM YYYY

DATEReceipt No

Processed by

Name

Checked by

Rechecked by

Coloured, recent & alike

Passport Size Photograph( 3 x 4 cm)

ATTESTEDon back

indicating name of candidate in

CAPITAL LETTERS& stapled

Coloured, recent & alike

Passport Size Photograph( 3 x 4 cm)

ATTESTEDon back

indicating name of candidate in

CAPITAL LETTERS& stapled

F. MCPS 5 (f.b@b@r) 20511

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F. MCPS 6 (f.b@b@r) 20511

Page -6

INSTRUCTIONS FOR FRESH CANDIDATES

The elgibility of candidates shall be determined on the basis of the certificates/documents submitted with theapplication form which will be treated as final and no further certificate/corrrespondence will be entertained after thesubmission of application form. The training (including rotations), must be completed one month before the date oftheory examination. However, the Log Book, attendance of mandatory workshops and any other requirement shouldbe completed on the date of submission of examination application forms

Attested Photocopies to be enclosed MBBS / BDS Degree (Provisional certificate is not acceptable).Valid Pakistan Medical & Dental Council (PMDC) Registration Certificate.Computerized N.I.C. Certificate of House Job from Institution recognized by PMDC/CPSP. Certificates of residency training Provide documentry proof for all training claimed for fullfilment of requirements including appointment letter, posting orders, experience certificates duly signed by approved supervisors and countersigned by head of institution. Certificates on personnal letterheads will not be accepted.a) All the Training Certificates must be on proper letterheads of institute giving dates of starting and

ending residency training in each speciality / sub-speciality and stamped with official seal showingname of signing authority.

b) Only those certificates of residency and other certificates will be accepted by the College for the purpose of

eligibility, which will be issued by the Supervisor, Head of the Unit and countersigned by Head of the recognized

Institution. Attention of the candidates is drawn to these requirements in the application form.

Two years of residency training after complition of one year of house job is required. Please give evidence

of completion of training, if not already submitted.

All fresh candidates are required to submit a certificate of registration from Research

and Training Monitoring Cell (RTMC) of CPSP.

All fresh candidates have to submit certificates of having attended all the required

mandatory workshops (No other docuements will be accepted).

a). Computer & Internet Orientation b). Communication Skills c). Primary /Basic Surgical Skills

Four coloured photographs recent and alike (size: 3cm x 4cm). One each to be pasted

in the box on application and enrollment form and got attested on front. Other photographs to be stapled in

the boxes provided in the application form. These photographs should indicate name of candidate in capital

letters and attested on the back.

Where applicable Certificate of having worked in Dark Room, Radio Isotope Centre, exposing of X-Ray

films (Diag. Radiology), administration of Anaesthesia and having performed required number of operations/

procedures according to the syllabus. (Note details in prospectus)

Log Book (prescribed by CPSP) complete in all respect and duly signed by SupervisorEvidence of having paid examination fee (Original Challan / Original bank draft / pay order). Please provide details (amount, number and date of submission) of Challan, demand draft and pay order.

Enrollment form (if not already enrolled)

Note: Admit cards issued to eligible candidates must be kept carefully as this has to be returned with the repeater’s application form. If this is not submitted penalty could be imposed.

2.10

2.8

2.7

2.6

2.5

2.4

2.3

2.2

2.1

2

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2.9

5

All attestation must be stamped with name and designation of the attester by ONE of the following

☛☛ Fellow of the College of Physicians & Surgeons Pakistan with his Fellowship Number.

☛☛ Principal/Professor of Medical Colleges/Postgraduate Medical Institutions.

☛☛ Medical Superintendent / Head of the Medical Institution.

LIST OF DOCUMENTS REQUIRED TO BE ENCLOSED WITH THE APPLICATION FORM

T h i s P a g e t o b e r e t a i n e d b y t h e c a n d i d a t e

34

Page -7

C H E C K L I S T F O R F R E S H C A N D I D A T E S

The eligibility of the candidate shall be determined on the basis of documents submitted with theapplication form which will be treated as final. Incomplete form will be rejected and nocorrespondence will be entertained after submission of application form.

Following documents are required to process application form for MCPS examination. Please check(✔) the appropriate box ÔYesÕ or ÔNoÕ. Explanation must be given on a separate page, if you havechecked (✔) ÔNoÕ to any of the documents.

1. House job Certificates ❑ ❑

2. Certificate of residency training. On institution’s letterhead signed by supervisor,

HOD and HOI (M.S., Dean, Assoc. Dean, Commandant, Principal) clearly mentioned

dates of training, reference number, date of issue with official seal. ❑ ❑

3. RTMC registration certificate for registered training ❑ ❑

4. Appointment order and joining report of training done including rotations.

(as applicable) ❑ ❑

5. Certificate of attendance of mandatory workshop (as applicable)

i. Introduction to Computer and Internet ❑ ❑

ii. Communication Skills ❑ ❑

iii. Basic Surgical Skills (For candidates appearing in Surgery & Allied Subjects) ❑ ❑

6. Computerized National Identity Card ❑ ❑

7. M.B.B.S / BDS, degree ❑ ❑

8. Valid PMDC registration certificate ❑ ❑

9. Four Passport size coloured, recent & alike photographs ❑ ❑

10. Evidence of having paid examination fee ❑ ❑(original bank draft/pay order, bank challan (Amount, No. and Date)

Postal order are not accepted.

11. Log Book prescribed by CPSP (as applicable) complete in all respect duly

signed by the Supervisor. ❑ ❑

12. Any other required document which the candidate has not submitted

13. Training must have been completed one month before the date of

theory examination.

Candidates must submit this sheet along with application form

Note: All the Photocopies must be attested. Attestation must be stamped with name anddesignation of the attester by one of the following.

● Fellow of CPSP with his Fellowship number ● Principal /Professor of Medical College/Postgraduate Medical Institute● Medical Superintendent/Head of the Medical Institution

YES NO.

F. MCPS 7 (f.b@b@r) 20511