College of Physicians & Surgeons Pakistan Repeater
Form No: 760-177121
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: 17-SEP-2019
Registration Type: Repeater
Enrolment No: F-19-01462
Examination Center: LAHORE
Selected Speciality: SURGERY AND ALLIED
Fee Type: Debit/Credit Card Fee Amount PKR 15050
Fee Submission City Lahore Transaction ID: 226452772810
Receipt #: LHR-O-19-13403 Receipt Date: 24-06-2019
Profile Information
Medical Reg. No: 92729-P
Medical Reg. issue date: 15-01-2019 Medical Reg. expiry date: 31-12-2021
Full Name: USMAN SADIQ
Father's name: MUHAMMAD SADIQ
Nationality: Pakistan Identity Card No: 34603-0991796-9
Gender: Male Marital Status: Single
Date of Birth: 03-04-1988
Email: saharah_us@yahoo.com
Present/Mailing Address (Residential Only)
Address: IMAM ALI UL HAQ ROAD, AMIR STREET, MODEL TOWN
Sialkot, Punjab, Pakistan
Tel (Res.): 0523301043 Tel (Office):
Cell: 03365200272 Postal Code:
Permanent Address (Residential Only)
Same as Mailing Add: Yes
Address: IMAM ALI UL HAQ ROAD, AMIR STREET, MODEL TOWN
Sialkot, Punjab, Pakistan
Tel (Res.): 0523301043 Tel (Office):
Cell: 03365200272 Postal Code:
Particulars of Last Examination Appeared
Roll Number: 62269 Date of Examination:
Enrolment: F-19-01462 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: 24-06-2019
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
College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan
Debit/Credit Card Debit/Credit Card
Center: Lahore PMDC/En.No: F-19-01462 Center: Lahore PMDC/En.No: F-19-01462
Receipt #: LHR-O-19-13403 Date: 24-06-2019 Receipt #: LHR-O-19-13403 Date: 24-06-2019
Name: USMAN SADIQ Name: USMAN SADIQ
Trans ID: 226452772810 Approval Code: 576065 Trans ID: 226452772810 Approval Code: 576065
Form No: 760-177121 Form No: 760-177121
Fee Type Session Amount Fee Type Session Amount
Exam Fee - FCPS-I SEP-2019 PKR 15050 Exam Fee - FCPS-I SEP-2019 PKR 15050
Bank Service Charges PKR 550 Bank Service Charges PKR 550
Total: PKR 15600 Total: PKR 15600
Amount in words: Fifteen Thousand Six Hundred Only (PKR) Amount in words: Fifteen Thousand Six Hundred 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.
____________________________ ____________________________ ____________________________ ____________________________
Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature
Contact No: ________________ Contact No: ________________
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