College of Physicians & Surgeons Pakistan

Form No: 2014-1377

7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99207100-09 , Fax: 99207120, 35881444, UAN: 111-606-606
Website: www.cpsp.edu.pk
Application Date: 10-10-2014
Workshop Registration Form

Full Name: AYESHA SALEEM
Father's Name: SALEEM AKHTAR
New NIC: 35202-7963224-6
Date of Birth: 09-09-1986
Gender/Marital Status: Female/Single
Email: DR.ASHI_SA86@HOTMAIL.COM
Registration Information
Program: FCPS Speciality: ANAESTHESIOLOGY
Country/State/City: Pakistan, Punjab, Rawalpindi
Institute: RAWALPINDI MEDICAL COLLEGE & ALLIED HOSPITALS
Supervisor: MUHAMMAD SHAFIQ Unit/Department:
RTMC #: ANS-2013-126-1344 CPSP ID: 2013-3965
Workshop(s) Details
# Workshop Name Center
1 Communication Skills ISLAMABAD
2 Introduction to Computer & Internet ISLAMABAD
3 Research Methodology, Biostatistics & Dissertation Writing ISLAMABAD
Present/Mailing Address (Residential Only)
Address: FLAT NO. 1, BLOCK NO. 3-E, A.G.P.R. COLONY SECTOR: G-9/2
Country/State/City: Islamabad, Punjab, Pakistan
Tel (Res.): 051-2300882 Tel (Office):
Cell: 0334-0555396 Postal Code:
Permanent Address (Residential Only)
Address: HOUSE NO.13, STREET NO.172 SECTOR: G-13/3
Country/State/City: Islamabad, Punjab, Pakistan
Tel (Res.): 051-2300882 Tel (Office):
Cell: 03314790069 Postal Code:
Fee Information
Fee Type: Bank Challan Fee Submission City: Islamabad
Currency: PKR Amount: 23000
Receipt #: ISL-C-14-4631 Receipt Date: 10-10-2014
Bank Name: UNITED BANK LTD
Branch Name: G-8, Al Markaz Branch, Islamabad (0234)
Declaration
Above is correct to the best of my knowledge. Incorrect information may lead to cancelation of enrollment / admission / results and disciplinary action.
Signature of Candidate: ________________________________Dated:10-10-2014
Note:
Overwriting or electronic change is not allowed on the hard copy of this application form otherwise form may be rejected.
Candidates are advised to attach a hand written application if they want to change their particulars.
page 1 / 3
ORIGINAL - Concerned Department
Branch: G-8, Al Markaz Branch, Islamabad (0234)Account #:
010-2220-2

College of Physicians and Surgeons Pakistan

DME
Bank Challan

Center: Islamabad CPSP ID:2013-3965

Receipt #: ISL-C-14-4631 Receipt Date:10-10-2014

Name: AYESHA SALEEM

Form No: 2014-1377

Fee Type

Amount

W/S Fees - Communication PKR8500

W/S Fees - I.T. Workshop PKR6000
W/S Fees - RMBDW PKR8500

Total: PKR23000
Amount in words: Twenty-Three Thousand Only (PKR)

____________________________
Candidate / Depositor Signature
____________________________
Receiver's Signature

Contact No: ________________

DUPLICATE - Applicant
Branch: G-8, Al Markaz Branch, Islamabad (0234)Account #:
010-2220-2

College of Physicians and Surgeons Pakistan

DME
Bank Challan

Center: Islamabad CPSP ID:2013-3965

Receipt #: ISL-C-14-4631 Receipt Date:10-10-2014

Name: AYESHA SALEEM

Form No: 2014-1377

Fee Type

Amount

W/S Fees - Communication PKR8500

W/S Fees - I.T. Workshop PKR6000
W/S Fees - RMBDW PKR8500

Total: PKR23000
Amount in words: Twenty-Three Thousand Only (PKR)

____________________________
Candidate / Depositor Signature
____________________________
Receiver's Signature

Contact No: ________________

page 2 / 3
TRIPLICATE - CPSP Finance
Branch: G-8, Al Markaz Branch, Islamabad (0234)Account #: 010-2220-2

College of Physicians and Surgeons Pakistan

DME
Bank Challan

Center: Islamabad CPSP ID:2013-3965

Receipt #: ISL-C-14-4631 Receipt Date:10-10-2014

Name: AYESHA SALEEM

Form No: 2014-1377

Fee Type

Amount

W/S Fees - Communication PKR8500

W/S Fees - I.T. Workshop PKR6000
W/S Fees - RMBDW PKR8500

Total: PKR23000
Amount in words: Twenty-Three Thousand Only (PKR)

____________________________
Candidate / Depositor Signature
____________________________
Receiver's Signature

Contact No: ________________

QUADRUPLICATE - Bank
Branch: G-8, Al Markaz Branch, Islamabad (0234)Account #: 010-2220-2

College of Physicians and Surgeons Pakistan

DME
Bank Challan

Center: Islamabad CPSP ID:2013-3965

Receipt #: ISL-C-14-4631 Receipt Date:10-10-2014

Name: AYESHA SALEEM

Form No: 2014-1377

Fee Type

Amount

W/S Fees - Communication PKR8500

W/S Fees - I.T. Workshop PKR6000
W/S Fees - RMBDW PKR8500

Total: PKR23000
Amount in words: Twenty-Three Thousand Only (PKR)

____________________________
Candidate / Depositor Signature
____________________________
Receiver's Signature

Contact No: ________________

page 3 / 3