College of Physicians & Surgeons Pakistan Form No: 215-11402
Training Session: Jul-2015
7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99207100-09 , Fax: 99207120, 35881444, UAN: 111-606-606 Application Date: 29-07-2015
Website: www.cpsp.edu.pk
FCPS-II Training Registration Form
Full Name: YASIR RAFIQUE RAJWANA
Father's Name: MALIK MUHAMMAD RAFIQUE RAJWANA
Nationality: Pakistan
NIC No: 36302-5464094-9
Date of Birth: 15-12-1985
Gender/Marital Status: Male / Single
Email:
[email protected] PMDC No: B-57185-P
PMDC Issue Date: 14-09-2009 PMDC Expiray Date: 23-03-2018
Registration Information
Program: 1st Fellowship
Speciality: MEDICINE
Country/State/City: Pakistan, Punjab, Multan
Institute: MULTAN MEDICAL & DENTAL COLLEGE/IBN-E-SIENA HOSPITAL
Supervisor: SIRAJ MUNIR AHMED TARIN Unit/Department:
Joining Date: 04-07-2015
Training Option: Will move to sub-speciality after two years
Subspeciality Group: Group 2
Present/Mailing Address (Residential Only)
Address: GOVERNOR HOUSE LAHORE.
Country/State/City: Lahore, Punjab, Pakistan
Tel (Res.): 042-99200011 Tel (Office):
Cell: 03004284474 Postal Code:
Permanent Address (Residential Only)
Same as Mailing Add: No
Address: 65/A RAJWANA ROAD AMEERABAD,
Country/State/City: Multan, Punjab, Pakistan
Tel (Res.): 061-4544532 Tel (Office):
Cell: 03004284474 Postal Code:
Basic Medical Qualification
Degree/Diploma: MBBS Passing Year: 2009
City/State/Country: Lahore, Punjab, Pakistan
Institute: KING EDWARD MEDICAL UNIVERSITY
FCPS-I Information
Speciality: MEDICINE AND ALLIED Roll No: 91218
Enrolment No: F-12-05375 Term Date: 12-11-2014
Fee Information
Fee Type: Bank Challan Fee Submission City: Lahore
Currency: PKR Amount: 3000
Receipt #: LHR-C-15-6648 Receipt Date: 29-07-2015
Bank Name: UNITED BANK LTD
Branch Name: Wahdat Road Branch, Lahore (1305)
Note:
Overwriting is not allowed on the hard copy of the application form nor any candidate is allowed to change his/her particular electronically
otherwise form may be rejected.
This application is valid for 4 months only. If rejected/ unaccepted it has to be resubmitted with registration fees.
Candidates are advised to attach a hand written application if they want to change their particulars.
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College of Physicians & Surgeons Pakistan Form No: 215-11402
Training Session: Jul-2015
7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99207100-09 , Fax: 99207120, 35881444, UAN: 111-606-606 Application Date: 29-07-2015
Website: www.cpsp.edu.pk
Supervisor's Consent
Name of Candidate: YASIR RAFIQUE RAJWANA
Institute & Dept.: MULTAN MEDICAL & DENTAL COLLEGE/IBN-E-SIENA HOSPITAL,
I am willing to supervise the above named FCPS-II trainee in the speciality of MEDICINE
Name of head of institution: _______________________________
Signature and stamp of head of institution: _______________________________
Name of supervisor: _______________________________
Signature of supervisor with stamp and RTMC #: _________________________________________________
Declaration
* The information given by me in this form is entirely correct. I am fully aware of the fact that in case a candidate gives wrong information on any
account, he/she is liable to punitive action by the CPSP, which may include cancellation of the registration and debarring from appearing in CPSP
RTMC for such period as may be specified by the CPSP.
* I undertake to keep the CPSP informed of the progress of training from time to time, as required. I also undertake to inform CPSP promptly in case of
transfer / change of supervisor, failing which the unregistered period of training is liable for cancellation besides imposing such penalty as may be
specified by CPSP.
Signature of Candidate: ________________________________ Dated: 29-07-2015
Documents to be enclosed:
Three coloured photographs (Standard passport size) one to be attested in front and two to be attested on the back.
Attested photocopies of following.
PMDC registration certificate(valid)
FCPS part 1 result / exemption letter
Appointment / Placement order issued by institution's administration department
Letter of joining from the department
M.B.B.S degree
Details required.
No. of trainee registered with the proposed supervisor
No. of beds in the relevant unit
Faculty members in the unit, duly verified from the head of institute
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ORIGINAL - Concerned Department DUPLICATE - Applicant
Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2 Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2
College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan
RTMC RTMC
Bank Challan Bank Challan
Center: Lahore Medical Ref/Enrol No: F-12-05375 Center: Lahore Medical Ref/Enrol No: F-12-05375
Receipt #: LHR-C-15-6648 Receipt Date: 29-07-2015 Receipt #: LHR-C-15-6648 Receipt Date: 29-07-2015
Name: YASIR RAFIQUE RAJWANA Name: YASIR RAFIQUE RAJWANA
Form No: 215-11402 Form No: 215-11402
Fee Type Session Amount Fee Type Session Amount
Registration Fee - FCPS Trainees Jul-2015 PKR 3000 Registration Fee - FCPS Trainees Jul-2015 PKR 3000
Total: PKR 3000 Total: PKR 3000
Amount in words: Three Thousand Only (PKR) Amount in words: Three Thousand Only (PKR)
____________________________ ____________________________ ____________________________ ____________________________
Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature
Contact No: ________________ Contact No: ________________
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TRIPLICATE - CPSP Finance QUADRUPLICATE - Bank
Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2 Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2
College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan
RTMC RTMC
Bank Challan Bank Challan
Center: Lahore Medical Ref/Enrol No: F-12-05375 Center: Lahore Medical Ref/Enrol No: F-12-05375
Receipt #: LHR-C-15-6648 Receipt Date: 29-07-2015 Receipt #: LHR-C-15-6648 Receipt Date: 29-07-2015
Name: YASIR RAFIQUE RAJWANA Name: YASIR RAFIQUE RAJWANA
Form No: 215-11402 Form No: 215-11402
Fee Type Session Amount Fee Type Session Amount
Registration Fee - FCPS Trainees Jul-2015 PKR 3000 Registration Fee - FCPS Trainees Jul-2015 PKR 3000
Total: PKR 3000 Total: PKR 3000
Amount in words: Three Thousand Only (PKR) Amount in words: Three Thousand Only (PKR)
____________________________ ____________________________ ____________________________ ____________________________
Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature
Contact No: ________________ Contact No: ________________
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