College of Physicians & Surgeons Pakistan

7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99266400-410 , Fax: 99266432, UAN: 111-606-606
Website: www.cpsp.edu.pk
Term: 24-AUG-2021

Online Application Form For IMM

Appearing In: Clinical ( Previous No of Attempts: 1 )

Fee Type: Bank Challan Fee Amount: PKR 15050
Fee Submission City Lahore
Receipt #: LHR-C-21-19358 Receipt Date: 21-05-2021
Bank Name: UNITED BANK LTD
Branch Name: Wahdat Road Branch, Lahore (1305)

Profile Information
CPSP ID: 2018-3355 Form No: 783-209120
Medical Reg. No: 51546-P
PMDC Issue/Exp. Date: 15-08-2007 ---- 31-12-2021 Repeater (Clinical)
Full Name: KIRAN SAEED
Father's Name: SHEIKH MUHAMMAD SAEED Lahore
Nationality: Pakistan
Identity Card No: 35202-8254994-0 MEDICINE (GROUP-A)
Date of Birth: 25-04-1981
Email: [email protected] CPSP ID: 2018-3355
Gender / Marital Status: Female / Single
FCPS-I Information: Passing Date: 14-05-2016 Roll No: F-16-01057 CRD-2021-274-2566

Present/Mailing Address (Residential Only)

Address: 363- B NASHTAR BLOCK,ALLAMA IQBAL TOWN
Lahore, Punjab, Pakistan
Tel (Res.): 042-35432348 Tel (Office): NA
Cell: 03009435622 Postal Code: 5400

Permanent Address (Residential Only)

Address: 363- B NASHTAR BLOCK,ALLAMA IQBAL TOWN
Lahore, Punjab, Pakistan
Tel (Res.): 042-35432348 Tel (Office): NA
Cell: 03009435622 Postal Code: 5400

Particulars of Last Examination Appeared

Roll Number: 61541 Date of Examination: 09-02-2021
Enrolment: Center: Lahore

Declaration
I do hereby declare that information given above is correct to the best of my knowledge. Incorrect information may lead to cancellation of enrollment /
admission / results and disciplinary action.

Signature of Candidate: ________________________________ Name: KIRAN SAEED

Dated: 21-05-2021

For quick and effective communication all correspondence with the candidates will be done through email rather than by postal means / courier.
Overwriting is not allowed on the hard copy of the application form nor any candidate is allowed to change his/her particular electronically.
If you have any problem then contact at this number: 021-99266400-410 Ext. 246 or email at [email protected].

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 College of Physicians & Surgeons Pakistan Repeater
Form No: 783-209120

7th Central Street, Defence Housing Authority Phase-II, Karachi -75500, Pakistan
Tel: 99266400-410 , Fax: 99266432, UAN: 111-606-606 Term: 24-AUG-2021
Website: www.cpsp.edu.pk

Follow the instructions given below before proceeding step-2

- Take a printout of your complete form.

- Pay your examination fee.

- In case of Pay Order submit the original to CPSP along with fee challan and upload the scan copy in step-2.

- Convert all your dcouments in PDF format.

- If you will submit your form in person / through courier, your form will not be accepted.

Upload Following Documents in Step-2

Please attach only scanned copies of original documements mentioned below.

(*) mark documents are mandatory.

- Step1 Application Form: * Duly signed by you.

- Challan / PO / D.D: * Scan copy of Paid Challan/ Pay Order/ Demand Draft.

- Photograph (300 Resolution in picture format): * One recent photograph with clear identity and attested from front.

- Last Admit Card: *

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 ORIGINAL - Concerned Department DUPLICATE - Applicant

Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2 Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2

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

Bank Challan Bank Challan

Fee should be deposited in CPSP booth / above branch. Fee should be deposited in CPSP booth / above branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Lahore RTMC No: CRD-2021-274-2566 Center: Lahore RTMC No: CRD-2021-274-2566

Receipt #: LHR-C-21-19358 Receipt Date: 21-05-2021 Receipt #: LHR-C-21-19358 Receipt Date: 21-05-2021

Name: KIRAN SAEED Name: KIRAN SAEED

Form No: 783-209120 Form No: 783-209120

Fee Type Session Amount Fee Type Session Amount

Exam Fee - IMM AUG-2021 PKR 15050 Exam Fee - IMM AUG-2021 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: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2 Branch: Wahdat Road Branch, Lahore (1305) Account #: 010-2468-2

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

Bank Challan Bank Challan

Fee should be deposited in CPSP booth / above branch. Fee should be deposited in CPSP booth / above branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Lahore RTMC No: CRD-2021-274-2566 Center: Lahore RTMC No: CRD-2021-274-2566

Receipt #: LHR-C-21-19358 Receipt Date: 21-05-2021 Receipt #: LHR-C-21-19358 Receipt Date: 21-05-2021

Name: KIRAN SAEED Name: KIRAN SAEED

Form No: 783-209120 Form No: 783-209120

Fee Type Session Amount Fee Type Session Amount

Exam Fee - IMM AUG-2021 PKR 15050 Exam Fee - IMM AUG-2021 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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