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SMBBMUL Form For Course or Program

The document is an application form for admission to degree, diploma, FCPS-II, and MCPS training programs at Shaheed Mohtarma Benazir Bhutto Medical University in Larkano, Pakistan. It requests personal information such as name, father's name, CNIC number, address, contact details, date of birth, religion, nationality, academic and professional qualifications, employment history, publications, references, and a declaration agreeing to abide by university rules. It also includes a checklist of required attested documents and sections for office use only including seat number, eligibility status, and receipt number.

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Ihsan Bhatti
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69 views4 pages

SMBBMUL Form For Course or Program

The document is an application form for admission to degree, diploma, FCPS-II, and MCPS training programs at Shaheed Mohtarma Benazir Bhutto Medical University in Larkano, Pakistan. It requests personal information such as name, father's name, CNIC number, address, contact details, date of birth, religion, nationality, academic and professional qualifications, employment history, publications, references, and a declaration agreeing to abide by university rules. It also includes a checklist of required attested documents and sections for office use only including seat number, eligibility status, and receipt number.

Uploaded by

Ihsan Bhatti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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

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