College of Physicians & Surgeons Pakistan

7th Central Street, Defence Housing Authority, Karachi -75500, Pakistan Tel: 9207100-09 , Fax: 9207120, 5881444, UAN: 111-606-606 Website: www.cpsp.edu.pk

Fresh
Form No: 684-17629

Online Application Form (FCPS-I) Examination

Term: Registration Type: Examination Center: Selected Speciality: Fee Type: Form Submission Center Receipt #: Number: Bank Name: Branch Name:

12-FEB-2014
Fresh

ABBOTTABAD MEDICINE AND ALLIED

Instrument (PO/DD/Cheque) Abbottabad ABT-I-13-503 B0963425 National Bank of Pakistan Sarai Naurang Branch (0964) Fee Amount Receipt Date: Date: Bank City: PKR 15050 03-11-2013 31-10-2013 Other

Profile Information
Medical Reg. No: Medical Reg. issue date: Full Name: Father's name: Nationality: Gender: Date of Birth: Email:

19100-N
22-11-2012 Medical Reg. expiry date: 31-12-2016

NAVEED AAMIR MUHAMMAD BASHIR KHAN

Pakistan Male 28-04-1988 Identity Card No: Marital Status: 11201-3386288-5 Single

naveed.aamir118@gmail.com

Present/Mailing Address (Residential Only)

Address: Tel (Res.): Cell: KOTKA KAKI JAN, POST OFFICE SERAI NAURANG Lakki Marwat, Khyber Pakhtunkhwa, Pakistan N/A Tel (Office): 03118889628 Postal Code:

N/A 28350

Permanent Address (Residential Only)

Same as Mailing Add: Address: Tel (Res.): Cell: Yes KOTKA KAKI JAN, POST OFFICE SERAI NAURANG Lakki Marwat, Khyber Pakhtunkhwa, Pakistan N/A Tel (Office): 03118889628 Postal Code:

N/A 28350

Professional Qualification
Institute: Degree: AYUB MEDICAL COLLEGE MBBS Passing Year: 2011

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.

Signature of Candidate: ________________________________ Dated: 03-11-2013 Note: Overwriting is not allowed on the hard copy of the application form nor any candidate is allowed to change his/her particular electronically. Once entered in the application the center and subject will only be changed after submission of prescribed fee for this change. Candidates are advised to attach a hand written application if they want to change their particulars.

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ORIGINAL

- Concerned Department

DUPLICATE

- CPSP Finance

TRIPLICATE

- Applicant

College of Physicians and Surgeons Pakistan Bank Instrument - Fee Receipt (Pay Order/Demand Draft)

College of Physicians and Surgeons Pakistan Bank Instrument - Fee Receipt (Pay Order/Demand Draft)

College of Physicians and Surgeons Pakistan Bank Instrument - Fee Receipt (Pay Order/Demand Draft)

Center: PMDC/En.No: Receipt #: Name: PO/DD #: Bank Name: Bank Branch: Branch City:

Abbottabad 19100-N ABT-I-13-503 NAVEED AAMIR B0963425 Date: 31-10-2013 Date: 03-11-2013

Center: PMDC/En.No: Receipt #: Name: PO/DD #: Bank Name: Bank Branch: Branch City: Form No: 684-17629

Abbottabad 19100-N ABT-I-13-503 NAVEED AAMIR B0963425 Date: 31-10-2013 Date: 03-11-2013

Center: PMDC/En.No: Receipt #: Name: PO/DD #: Bank Name: Bank Branch: Branch City: Form No: 684-17629

Abbottabad 19100-N ABT-I-13-503 NAVEED AAMIR B0963425 Date: 31-10-2013 Date: 03-11-2013

National Bank of Pakistan Sarai Naurang Branch (0964) Other

National Bank of Pakistan Sarai Naurang Branch (0964) Other

National Bank of Pakistan Sarai Naurang Branch (0964) Other Form No: 684-17629

Fee Type Exam Fee - FCPS-I

Session FEB-2014

Amount PKR 15050 Fee Type Session FEB-2014 Amount PKR 15050 Total:

Fee Type Exam Fee - FCPS-I

Session FEB-2014

Amount PKR 15050

Total:

PKR 15050

Exam Fee - FCPS-I

PKR 15050

Amount in words: Fifteen Thousand and Fifty Only (PKR)

Amount in words: Fifteen Thousand and Fifty Only (PKR)

Total:

PKR 15050

Amount in words: Fifteen Thousand and Fifty Only (PKR)

_________________________ Candidate / Depositor Signature Contact No: ________________

_________________ Receiver's Signature _________________________ Candidate / Depositor Signature Contact No: ________________ _________________ Receiver's Signature

_________________________ Candidate / Depositor Signature Contact No: ________________

_________________ Receiver's Signature

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