College of Physicians & Surgeons Pakistan Repeater

Form No: 769-220181

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

Online Application Form (FCPS-I) Examination

Term: 15-JUN-2020
Registration Type: Repeater
Enrolment No: F-20-00360
Examination Center: MULTAN
Selected Speciality: SURGERY AND ALLIED
Fee Type: Debit/Credit Card Fee Amount PKR 25000
Fee Submission City Lahore Transaction ID: 210762545775
Receipt #: LHR-O-20-10503 Receipt Date: 21-05-2020

Profile Information
Medical Reg. No: 100536-P
Medical Reg. issue date: 19-12-2018 Medical Reg. expiry date: 31-12-2022
Full Name: OZAIR BILAL AHMED
Father's name: BILAL AHMAD
Nationality: Pakistan Identity Card No: 31102-2633746-3
Gender: Male Marital Status: Single
Date of Birth: 25-12-1993
Email: ozairbilal@live.com

Present/Mailing Address (Residential Only)

Address: HOUSE NUMBER 97, BEHIND FATIMA PLAZA OLD EID GAH ROAD
Chishtian, Punjab, Pakistan
Tel (Res.): 0632440077 Tel (Office):
Cell: 03007877134 Postal Code:

Permanent Address (Residential Only)

Same as Mailing Add: Yes
Address: HOUSE NUMBER 97, BEHIND FATIMA PLAZA OLD EID GAH ROAD
Chishtian, Punjab, Pakistan
Tel (Res.): 0632440077 Tel (Office):
Cell: 03007877134 Postal Code:

Particulars of Last Examination Appeared

Roll Number: 61512 Date of Examination:
Enrolment: F-20-00360 Center:

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: 21-05-2020

Note:

Once entered in the application the center and subject will only be changed after submission of prescribed fee for this change.

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 ORIGINAL - Concerned Department DUPLICATE - Applicant

College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan

Debit/Credit Card Debit/Credit Card

Center: Lahore PMDC/En.No: F-20-00360 Center: Lahore PMDC/En.No: F-20-00360

Receipt #: LHR-O-20-10503 Date: 21-05-2020 Receipt #: LHR-O-20-10503 Date: 21-05-2020
Name: OZAIR BILAL AHMED Name: OZAIR BILAL AHMED
Trans ID: 210762545775 Approval Code: 381352 Trans ID: 210762545775 Approval Code: 381352

Form No: 769-220181 Form No: 769-220181

Fee Type Session Amount Fee Type Session Amount

Exam Fee - FCPS-I JUN-2020 PKR 25000 Exam Fee - FCPS-I JUN-2020 PKR 25000

Bank Service Charges PKR 925 Bank Service Charges PKR 925

Total: PKR 25925 Total: PKR 25925

Amount in words: Twenty-Five Thousand Nine Hundred and Twenty-Five Only (PKR) Amount in words: Twenty-Five Thousand Nine Hundred and Twenty-Five Only (PKR)

Note: Note:
In case of any refund/charge back against cards transaction through internet payment In case of any refund/charge back against cards transaction through internet payment
gateway, the candidate should claim the refund/charge back from CPSP directly. gateway, the candidate should claim the refund/charge back from CPSP directly.

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