RTMC Registration No

Last Exam Session

PMDC Registration No

Last Exam Roll No

Chosen Speciality for examination

Chosen centre of examination

Name (As per MBBS, Degree)

Name of Father / Husband

SUPERVISOR DETAILS

Name:

Designation & Name of Institution

RTMC Registration No.

A candidate who does not appear in the immediately following TOACS examination after passing theoryexamination will lose one chance. Only two out of three consecutive chances will be available to such candidates.

Price Rs. 50/=7th Central Street, D.H.A. Phase II,Karachi-75500 (Pakistan)Tel: 99207100-10Fax: 99207120, 35881444UAN: 111-606-606E-mail: examinations@cpsp.edu.pkWeb-site: w w w . c p s p . e d u . p k

NOW APPEARING AS:(Please tick mark appropriate box)

REPEATER OF THEORYREPEATER OF TOACS

IMMWEBCOPY

REPEATER CANDID

ATE

APPEA

RING IN

SAUDI A

RABIA A

T

RIYADH

APPLICATION FORMINTERMEDIATE MODULE

OCTOBER 09, 2012ALL ENTRIES TO BE MADE IN INK AND

FILL ALL COLUMNS IN BLOCK LETTERS

Coloured, recent & alike

Passport Size Photograph( 5 x 6 cm)Pasted &

attested on front

Anaesthesiology, Dentistry (Operative Dentistry), Dentistry (Oral & Maxillofacial Surgery), Dentistry (Orthodontics),

Dentistry (Prosthodontics) Diagnostic Radiology, Medicine, Obstetrics & Gynae, Ophthalmology, Otorhinolaryngology,

Paediatrics, Psychiatry, Surgery

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Amount No./Date Bank Branch

EXAMINATION FEE

Challan United Bank Ltd.

Bank Draft

Pay Order

PRESENT STATUS(Tick Mark Appropriate Box)

Employed Self Employed

If employed:

Designation

Name of Institution

Address of Institution

Name of Immediate Supervising Officer

PRESENT MAILING ADDRESS (Residential Only)

Date of Birth

--

DD MM YYYY

.ONEDOC AERA

Marital Status Married Single

Nationality Sex Male Female

City Country

C.N.I.C

Tel (Res) .ONEDOC AERAOffice

.ONEDOCCell Email

PERMANENT ADDRESS (If different from above)

--

.ONEDOC AERATel (Res) .ONEDOC AERAOffice

City Country

--

--

--

--

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DECLARATION BY CANDIDATE

I, Dr.

S/o D/o W/o

Do solemnly declare that all the information provided above is correct. Incorrect information maylead to cancellation of enrollment / admission / results and disciplinary action.

DD MM YYYY

DATE SIGNATURE OF CANDIDATE

INCOMPLETE APPLICATION WILL NOT BE PROCESSED

LIST OF DOCUMENTS REQUIRED TO BE ENCLOSED WITH THE APPLICATION FORM

1. Evidence of having paid examination fee (original Bank Draft / Pay Order)

2. Three coloured photographs taken recently and of prescribed size (5cm x 6 cm). One to be pasted in the

box on each form and got attested on front. Other photographs to be stapled in the box provided in the

application forms. These photographs should indicate name of candidate in capital letters and attested on

the back.

3. Last Admit Card is to be returned with present application. The Admit Card for the present examination will

be issued only when the last Admit Card has been returned. In case the admit card has been lost, penalty

could be imposed.

4. Valid PMDC Certificate

5. In case the candidate is repeating the examination after a period of more than three calendar years he/she should

apply on the application form prescribed for “Fresh Candidates” and attach all the required documents again.

6. Any other relevant document which needs to be submitted with this application form.

COLOURED recent & alike

PHOTOGRAPHPassport Size

( 5 x 6 cm)ATTESTED

on back indicating name of

candidate in CAPITAL LETTERS

& stapled

COLOURED recent & alike

PHOTOGRAPHPassport Size

( 5 x 6 cm)ATTESTED

on back indicating name of

candidate in CAPITAL LETTERS

& stapled

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FOR OFFICE USE ONLY

DD MM YYYY

DATEReceipt No.

Processed by

Name

Checked by

Rechecked by

LAST INTERMEDIATE MODULEEXAMINATION

ADMIT CARD

(Staple Here)

C H E C K L I S T F O R R E P E AT E R C A N D I D A T E S

The eligibility of the candidate shall be determined on the basis of documents submitted with theapplication form which will be treated as final. Incomplete form will be rejected and nocorrespondence will be entertained after submission of application form.

Following are the documents required to process application form for IMM examination.Please check( ) the appropriate box or . Explanation must be given on a separate page, if you havechecked ( ) to any of the documents.

1. Three Passport size coloured recent & alike photographs

2. Evidence of having paid examination fee (original bank draft/pay order. Bank Challan (Amount, No. and Date)

Postal order are not accepted)

3. Last Admit Card

4. Valid PMDC Certificate

Candidates must submit this sheet along with application formNote: All the Photocopies must be attested. Attestation must be stamped with name and

designation of the attester by one of the following.

Fellow of CPSP with his Fellowship number Principal / Professor of Medical College/Postgraduate Medical InstituteMedical Superintendent / Head of the Medical Institution

YES NO.

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