DISCLOSURE FORM

CONSENT TO RELEASE OF INFORMATION

TO THE PAKISTAN MEDICAL AND DENTAL COUNCIL

I…………………………………..………………..(full name) hereby authorize the Pakistan Medical and

Dental Council (PM&DC), to obtain verification and all necessary information for purposes of
verification of my credentials from the granting institution/authority or any other authority as
the case may be.

I shall directly pay to the institution/authority the fee, if any, that may be charged for
verification by the institution/authority who is requested to provide the verification provider.

The Pakistan Medical and Dental Council is not bound to any confidentiality in respect of
verification and information received by it in pursuance of my request.

SIGNATURE OF APPLICANT/DOCTOR