‘Aephenon Ferm AP 02) +2: ; FEDERAL POSTGRADUATE MEDICAL INSTITUTE 4 SHAIKH ZAYED POSTGRADUATE MEDICAL INSTITUTE, Se LAHORE-54600 Space for Photograph Form No. Course Session, Challan No. Date. (Attach original paid Challan) Course Title: Fee PERSONAL INFORMATION 1. Name. ae {in block letters) (surname) (First) (Middle) 2. P.M.D.C. No. Sex: [Male [ ] Female 3. Date of Birth Place of Birth ‘4. Nationality National ID No. + 5. Father's Name 6. Spouse Name Occupation Nationality 7. Martial Status: [] Single []Married [] Divorced [ ] Widow 8. Children (mention names & ages) 9. Address (Indicate where you wish your correspondence to be sent) [1 Permanent Phone. [Postal Phone 10. Domicile: [ ] Punjab {]Sindh- Urban —_[ ] Sindh Rural [] NWFP [ ] Baluchistan [JFATA. ] A. J. Kashmir14. Curriculum leading to Degree / Diploma of: LDA [10.C.H L10.c.P 110,G.0 [10.0 : []DMRD []DMRT []DOMS [ ]D17.CD Lm CMs {]MPhil [J R.C.PS Parti: 12. Academic Qualifications : Quatieation Roll Mo. Yoar marks * Anempt College. Quatiied- — | Aggregate Aggregate A mess Ist Proft 2nd Prott 3nd Proft Ss C B._Othors ©. Academic Position Position Dictinction Medals Honours % tmnt. in College 1. Research’ Publications (Give details separately) 13. Practical Experience = Experlence Medical Officer | Total From to Subject tnatitution Namo of Prot registrar / demonstrator durationty.ay | date 1 Had of Dont ‘A House Job iz 2 « es 8. Senior Registrar Any Other = 14, Govt. Servic [ ] Province 1] Federal []_ Autonomous Appointment: ©) Contract 1) Adhoe [1] Regular Public Service Commission: ‘ 1] Federal [] Autonomous 15. Private Service, Please Specify Please check below the amount of time you have been away from the academic institution {) 1 (] Yt Less 2-5 Yrs. 5-10 Yrs. 10 Yrs. | More16 7. 18. 19 ‘State whether subject to any linary acti Any Physical, psychological handicap . Personal interests, hobies etc. REFERENCES : : List of the names of two individuals with knowledge of your abilities in the area of your academic aptitude and achievement and / or in carrying out professional work and responsibilities. Name and title Address Phone (2) Incomplete applications will not be considered for admission. (b) Duly attested documentary proof of all statements made must. accompany the applications. (c) Three passport size recent photographs are to be attached with the applications. (4) Reference letters can be provided in sealed envelops, or mailed directly. DECLARATION do hereby declare that the above particulars are correct in every respect and that | have not concealed any thing. also agree to appear in the entrance examination for the selection of candidates for the course if decided by the Federal Prstgraduate Medical institute, Lahore. Ishall abide by all the rules & regulations as set by Federal Postgraduate Medical Institute and the concerned University! College of Physicians and Surgeons from time to time. | also agree that if | do not show satisfactory progress | may be taken off the cours Daie Signature * Give details separately For Official Use only Name: Nationality: NID. No. Sex []Male [] Female Age: PM.D.C. No. Father's Name: Course Title Spouse Name: Nationality: Course Fees: Rs.