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Price Rs. 50/=
7th Central Street, D.H.A. Phase II, Karachi-75500 (Pakistan) Tel: 99207100-09; Fax: 99207120, 35881444 UAN: 111-606-606 E-mail: examinations@cpsp.edu.pk Web-site: www.cpsp.edu.pk

FR

APPLICATION FORM FCPS - I EXAMINATION NOVEMBER 16, 2011

ALL ENTRIES TO BE MADE IN INK AND IN BLOCK LETTERS

Coloured, recent & alike Passport Size Photograph ( 5 x 6 cm) Pasted & attested on front

Name (As given in MBBS/BDS Degree) Name of Father / Husband Date of Birth Nationality C.N.I.C D M Y

Marital Status

Married u Male u

Single u Female u -

Sex

PRESENT MAILING ADDRESS (Residential) City Tel (Res) Cell

AREA CODE
-

Country
AREA CODE
-

NO.

Office Email

NO.

CODE

NO.

PERMANENT ADDRESS (If different from above) City Country

-

Tel (Res)

AREA CODE

NO.

Office

AREA CODE

NO.

(If you do not have a telephone at your residence & office, please give a telephone number of your relative/friend through whom messages could be conveyed to you)
F. FCPS-I 1 (f.babar) 13611

PROFESSIONAL QUALIFICATIONS Qualification & Date of Graduation

Name of Institution

No & Date of PMDC Registration

House Job

EXPERIENCE

SPECIALITY

EXPERIENCE SINCE GRADUATION NAME OF INSTITUTION

From
M M

DATE
Y Y D D

D D

To
M M

Y Y

Any Other

Supported by a certificate clearly indicating that one year house job has been completed from PMDC approved institution, at least two months before the date of examination.
CHOOSE & FILL IN ONE SPECIALITY UNDER CHOSEN SPECIALITY OUT OF THE FOLLOWING IN BLOCK LETTERS CHOSEN SPECIALITY

1. 2. 3. 4. 5. 6.

Anaesthesia Dentistry Diagnostic Radiology Medicine & Allied Obstetrics & Gynaecology Ophthalmology

7. Otorhinolaryngology (ENT) 8. Pathology 9. Psychiatry 10. Surgery and Allied 11. Community Medicine
CHOSEN CENTRE

CHOOSE & FILL IN ONE CENTRE UNDER CHOSEN CENTRE FOR EXAMINATION 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

No/Date Challan Bank Draft Pay Order

EXAMINATION FEE Bank United Bank Ltd.

Branch

City

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

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Name, address & telephone Nos. of attester of documents

(The attester should be one of the followings:)

i) ii)

Fellow of the College of Physicians & Surgeons Pakistan with his Fellowship Number. Principal/Professor of PMDC approved Medical Colleges / Postgraduate Medical Institutions Medical Superintendent / Head of the Medical Institution.

1. 2.

I, Dr. S/o D/o W/o

DECLARATION

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

Coloured, recent & alike

PHOTOGRAPH
Passport Size ( 5 x 6 cms)

SIGNATURE OF CANDIDATE

on back indicating name of candidate in CAPITAL LETTERS & stapled

ATTESTED

FO R O F F I CE US E O NLY
Receipt No. Name of applicant Processed by Checked by Rechecked by Page -3
D

DATE
M

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

LIST OF DOCUMENTS REQUIRED TO BE ENCLOSED WITH THE APPLICATION FORM

INSTRUCTIONS

The eligibility of the candidates shall be ascertained on the basis of certificates of the correspondence shall be made in this regard.

requirements submitted with this application form which will be treated as final. No further Attested Photocopies of following documents to be enclosed
i. ii.

MBBS /BDS Degree

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

candidates, valid registration certificate of their own countrys medical council, equated Certificate of One Year House Job from institutions recognized by PMDC, duly counter the date of examination i.e. by September 16, 2011 for November 16, 2011 examination.

iii.

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

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.
5

Attested photocopy of Computerised National Identity Card.

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 number of candidates and logistic facilities available in a city irrespective of the choice given in the Box above.
F. FCPS-I 4 (f.babar) 13611

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