Rs.
200/-
SHAHEED MOHTARMA BENAZIR BHUTTO
MEDICAL UNIVERSITY, LARKANO
PHOTOGRAPH
APPLICATION FORM (Pasted)
FOR ADMISSION TO
DEGREE / DIPLOMA / FCPS-II / MCPS TRAINING PROGRAMS
ACADEMIC SESSION: JANUARY, 2020
Course / Program Applied For
Specialty / Sub-Specialty
Fee Paid Rs. Name of Bank:
Challan / Draft / Pay Order No. Dated:
PERSONAL INFORMATION (IN CAPITAL LETTERS)
Name: Marital Status:
Father’s Name:
Husband’s Name:
Computerized National Identity Card (CNIC) No.
Name of employer / organization:
(for in-service candidates only)
Present Posting / Position :
Address : (Present)
(Permanent)
Telephone no(s) Off : Residence :
Cell : E-mail :
Date of Birth: Domicile :
Religion : Nationality :
PMDC Registration No. : Valid upto :
Passport No. : Country :
(for foreign applicants only)
Candidate’s Signature :
ACADEMIC RECORD
Year of Graduation :
EXAMINATION MARKS OBTAINED
YEAR NUMBER OF ATTEMPTS INSTITUTION
PASSED (OUT OF TOTAL)
First Prof:
Second Prof:
Third Prof:
Fourth Prof:
Final Prof:
Post-graduation (if any):
RECORD OF JOB EXPERIENCE / EMPLOYMENT / RESIDENCY
NATURE OF JOB DESCRIPTION / SPECIALTY DURATION INSTITUTION
1. House Job a)
b)
c)
d)
2. All Jobs
(mention in chronological
order including Rural
Service if any)
(Attach additional sheet, if necessary)
PUBLICATIONS IN PMDC RECOGNIZED JOURNALS
SR. NO. TITLE AUTHORSHIP STATUS ISSUE OF JOURNALS
1ST, 2ND, 3RD
(Attach additional sheet, if necessary)
LIST OF COURSES / WORKSHOPS / TRAININGS ATTENDED (IF ANY)
(Attach additional sheet, if necessary)
REFERENCES :
Name of two reputed and responsible persons
REFERENCE – 1 REFERENCE - 2
Name: Name:
Position: Position:
Address: Address:
Tel. # Res: Mobil: Tel. # Res: Mobil:
DECLARATION
I SOLEMNLY DECLARE THAT THE INFORMATION FURNISHED IN THIS APPLICATION
FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERTAKE THAT
I SHALL ABIDE ALL THE RULES & REGULATIONS OF POSTGRADUATE STUDIES SMBBMU,
AND ANY CHANGES MADE BY THE UNIVERSITY AUTHORITIES FROM TIME TO TIME,
WITHOUT PRIOR NOTICE.
Date: ________________________ CANDIDATE’S SIGNATURE
Please read and follow the instructions before filling up the application form
Instructions:
1. Please complete all the parts, incomplete / short documented form will not be entertained.
2. Please write in CAPITAL letters.
3. Attach all attested photocopies of relevant documents.
4. Separate form to be filled for each course.
CHECK LIST OF DOCUMENTS (ATTESTED)
Please fill all the columns & tick as appropriate Y N
1. MBBS degree certificate
2. Valid PMDC Certificate
3. One Year House job certificate (with preferably 06 months in the relevant specialty)
4. MPH Degree Certificate (for Ph.D only)
5. Certificate of other qualification (if any)
6. Certificate of present posting / employment (if any)
7. Publication(s) (if any)
8. Matriculation certificate
9. Intermediate certificate
10. Computerized National Identity Card
11. Domicile certificate of the candidate
12. Experience certificate in relevant filed (if applicable)
13. Letter of congratulation of FCPS – I (for FCPS Candidates only)
14. Consolidated/Transcript or separate marks certificates of all professional examinations
(for FCPS Candidates only)
Date: ________________________ Signature of Candidate
FOR OFFICE USE ONLY
Serial No. __________________________ Documents: Complete / Incomplete ____________________________________
Eligible :_________________________ Not Eligible :_________________________ Receipt No ._________________________
(Signature of Director)
Postgraduate Studies, SMBBMU @ CMC, Larkano
SHAHEED MOHTARMA BENAZIR BHUTTO
MEDICAL UNIVERSITY, LARKANO
PHOTOGRAPH
ADMIT SLIP (Pasted)
Degree / Diploma / FCPS-II / MCPS Training programs
Academic Session: January, 2020
CENTRE SEAT NO.
Course / Program Applied For
Specialty / Sub-Specialty
Name: _____________________________________________________________________________
S/o, D/o, W/o:_____________________________________ CNIC No._________________________
Signature of Candidate Signature of Director with Seal Signature of Controller with Seal
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
SHAHEED MOHTARMA BENAZIR BHUTTO
MEDICAL UNIVERSITY, LARKANO
PHOTOGRAPH
ADMIT SLIP (Pasted)
Degree / Diploma / FCPS-II / MCPS Training programs
Academic Session: January, 2020
CENTRE SEAT NO.
Course / Program Applied For
Specialty / Sub-Specialty
Name: _____________________________________________________________________________
S/o, D/o, W/o:_____________________________________ CNIC No._________________________
Signature of Candidate Signature of Director with Seal Signature of Controller with Seal
