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College of Physicians & Surgeons Pakistan Form No: 121-59249

Training Session: Jan-2021


7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99207100-09 , Fax: 99207120, 35881444, UAN: 111-606-606 Application Date: 05-01-2021
Website: www.cpsp.edu.pk

FCPS-II Training Registration Form

Full Name: ABDULLAH SUBHAN


Father's Name: MUHAMMAD SUBHAN
Nationality: Pakistan
NIC No: 17201-2758603-5
Date of Birth: 29-11-1994
Gender/Marital Status: Male / Single
Email: abdullah1subhan@gmail.com PMDC No: 30283-N
PMDC Issue Date: 15-04-2019 PMDC Expiray Date: 31-12-2023

Registration Information
Program: 1st Fellowship
Speciality: MEDICINE
Country/State/City: Pakistan, Khyber Pakhtunkhwa, Peshawar
Institute: KHYBER MEDICAL COLLEGE / KHYBER TEACHING HOSPITAL
Supervisor: JAMAL-UD-DIN Unit/Department: E
Joining Date: 05-01-2021
Training Option: Will move to sub-speciality after two years
Subspeciality Group: Group 1

Present/Mailing Address (Residential Only)


Address: HOUSE 698, STREET 21, SECTOR E6, PHASE 7, HAYATABAD
Country/State/City: Peshawar, Khyber Pakhtunkhwa, Pakistan
Tel (Res.): Tel (Office):
Cell: 03365813344 Postal Code:

Permanent Address (Residential Only)


Same as Mailing Add: Yes
Address: HOUSE 698, STREET 21, SECTOR E6, PHASE 7, HAYATABAD
Country/State/City: Peshawar, Khyber Pakhtunkhwa, Pakistan
Tel (Res.): Tel (Office):
Cell: 03365813344 Postal Code:

Basic Medical Qualification


Degree/Diploma: MBBS Passing Year: 2019
City/State/Country: Peshawar, Khyber Pakhtunkhwa, Pakistan
Institute: KHYBER MEDICAL COLLEGE

FCPS-I Information
Speciality: MEDICINE AND ALLIED Roll No: 101155
Enrolment No: F-20-03877 Term Date:

Fee Information
Form Submission Center Peshawar Transaction ID: 237063217264
Receipt #: PSH-O-21-1437 Receipt Date: 05-01-2021

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.

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College of Physicians & Surgeons Pakistan Form No: 121-59249
Training Session: Jan-2021
7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99207100-09 , Fax: 99207120, 35881444, UAN: 111-606-606 Application Date: 05-01-2021
Website: www.cpsp.edu.pk

Supervisor's Consent

Name of Candidate: ABDULLAH SUBHAN

Institute & Dept.: KHYBER MEDICAL COLLEGE / KHYBER TEACHING HOSPITAL, E

I am willing to supervise the above named FCPS-II trainee in the speciality of MEDICINE. I declare that trainee is
not my close relative.

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.

* I declare that supervisor is not my close relative.

Signature of Candidate: ________________________________ Dated: 05-01-2021

Original Documents to be upload in step-2:

Step1 complete application form duly signed by Supervisor, Head of Institute and yourself as an applicant.
Scan copy of Paid Challan/ Pay Order/ Demand Draft.
One recent colour photograph with clear identity and attested from front.
Valid PMDC registration certificate.
FCPS part 1 result / exemption letter.
Appointment / placement order issued by institution's administration department.
Letter of joining from the department.
MBBS/BDS degree.
If there is any change in particulars please attach your written application.
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

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

R&RC R&RC
Debit/Credit Card Debit/Credit Card

Center: Peshawar PMDC/En.No: F-20-03877 Center: Peshawar PMDC/En.No: F-20-03877


Receipt #: PSH-O-21-1437 Date: 05-01-2021 Receipt #: PSH-O-21-1437 Date: 05-01-2021
Name: ABDULLAH SUBHAN Name: ABDULLAH SUBHAN
Trans ID: 237063217264 Approval Code: 226316 Trans ID: 237063217264 Approval Code: 226316

Form No: 121-59249 Form No: 121-59249

Fee Type Session Amount Fee Type Session Amount

Registration Fee - FCPS Trainees Jan-2021 PKR 3000.00 Registration Fee - FCPS Trainees Jan-2021 PKR 3000.00

Bank Service Charges PKR 150.00 Bank Service Charges PKR 150.00

Total: PKR 3150.00 Total: PKR 3150.00

Amount in words: Three Thousand One Hundred and Fifty Only (PKR) Amount in words: Three Thousand One Hundred and Fifty 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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