College of Physicians & Surgeons Pakistan Fresh

Form No: 761-182077

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 Examination

Online Application Form (FCPS-I) Examination

Term: 19-NOV-2019
Registration Type: Fresh
Examination Center: PESHAWAR
Selected Speciality: MEDICINE AND ALLIED
Fee Type: Bank Challan Fee Amount PKR 15050
Fee Submission City Peshawar
Receipt #: PSH-C-19-10522 Receipt Date: 16-08-2019
Bank Name: UNITED BANK LTD
Branch Name: Hayatabad Branch, Phase I, Peshawar (1112)

Profile Information
Medical Reg. No: 27612-N
Medical Reg. issue date: 15-05-2018 Medical Reg. expiry date: 31-12-2022
Full Name: SAGUL
Father's name: KIFAYAT ALI
Nationality: Pakistan Identity Card No: 17201-8316488-2
Gender: Female Marital Status: Single
Date of Birth: 27-10-1991
Email: [email protected]

Present/Mailing Address (Residential Only)

Address: HOUSE NO-814 STREET NO-5 SECTOR F-8 PHASE 6 HAYATABAD
Peshawar, Khyber Pakhtunkhwa, Pakistan
Tel (Res.): Tel (Office):
Cell: 03349178834 Postal Code: 25000

Permanent Address (Residential Only)

Same as Mailing Add: Yes
Address: HOUSE NO-814 STREET NO-5 SECTOR F-8 PHASE 6 HAYATABAD
Peshawar, Khyber Pakhtunkhwa, Pakistan
Tel (Res.): Tel (Office):
Cell: 03349178834 Postal Code: 25000

Professional Qualification
Degree: MBBS Passing Year: 2017
Institute: PAK INTERNATIONAL MEDICAL COLLEGE
City/State/Country: Peshawar, Khyber Pakhtunkhwa, Pakistan

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: 16-08-2019

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

Branch: Hayatabad Branch, Phase I, Peshawar (1112) Account #: Branch: Hayatabad Branch, Phase I, Peshawar (1112) Account #:
010-1009-8 010-1009-8

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

Bank Challan Bank Challan

Fee should be deposited in above mentioned branch. Fee should be deposited in above mentioned branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Peshawar Reg/Enrol/Fellowship No: 27612-N Center: Peshawar Reg/Enrol/Fellowship No: 27612-N

Receipt #: PSH-C-19-10522 Receipt Date: 16-08-2019 Receipt #: PSH-C-19-10522 Receipt Date: 16-08-2019

Name: SAGUL Name: SAGUL

Form No: 761-182077 Form No: 761-182077

Fee Type Session Amount Fee Type Session Amount

Exam Fee - FCPS-I NOV-2019 PKR 15050 Exam Fee - FCPS-I NOV-2019 PKR 15050

Total: PKR 15050 Total: PKR 15050

Amount in words: Fifteen Thousand and Fifty Only (PKR) Amount in words: Fifteen Thousand and Fifty 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: Hayatabad Branch, Phase I, Peshawar (1112) Account #: Branch: Hayatabad Branch, Phase I, Peshawar (1112) Account #:
010-1009-8 010-1009-8

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

Bank Challan Bank Challan

Fee should be deposited in above mentioned branch. Fee should be deposited in above mentioned branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Peshawar Reg/Enrol/Fellowship No: 27612-N Center: Peshawar Reg/Enrol/Fellowship No: 27612-N

Receipt #: PSH-C-19-10522 Receipt Date: 16-08-2019 Receipt #: PSH-C-19-10522 Receipt Date: 16-08-2019

Name: SAGUL Name: SAGUL

Form No: 761-182077 Form No: 761-182077

Fee Type Session Amount Fee Type Session Amount

Exam Fee - FCPS-I NOV-2019 PKR 15050 Exam Fee - FCPS-I NOV-2019 PKR 15050

Total: PKR 15050 Total: PKR 15050

Amount in words: Fifteen Thousand and Fifty Only (PKR) Amount in words: Fifteen Thousand and Fifty Only (PKR)

____________________________ ____________________________ ____________________________ ____________________________

Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature

Contact No: ________________ Contact No: ________________

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