APPLICATION FOR RESIDENCY/HOUSESTAFF EXTERNSHIP AT SKMCH&RC

FIRST NAME: _______________________ MIDDLE INITIAL: _____

LAST NAME: ____________________
DATE OF BIRTH: _______________________

SEX: _____________

NATIONALITY: ______________________
ADDRESS: ______________________________________________________CITY:______________
COUNTRY: _____________

POSTAL / ZIP CODE: _____________

TEL.________________________

FAX: ____________________________

EMAIL (Please print): ___________________________________________________________________

INSTITUTION & ADDRESS: _____________________________________________________________

Medical School attended:

__________________________________________________________________
(Name and Location)
_________________________________________________________________ .
Date of Graduation: ___ /___ /___

Requested Externship dates: From ___ /___ /200 __

To

___ /___ /200 __

REQUESTED DISCIPLINE (Rank in order of preference, from 1 to 5 with the first preference ranked as 1)

Anesthesia

Research

Nuclear
Medicine

Clinical
Nutrition

Radiation
Medicine

Radiology

Internal
Medicine

Pathology

Surgical
Oncology

Medical
Oncology
Pediatric
Oncology
Other
___________
_

Brief description of your objective for this Externship:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ACCOMMODATION REQUIRED (Rooms assigned based on availability):
APPLICANT'S SIGNATURE: _________________________________

(1) NO

(2) YES

DATE: ______________

TO BE COMPLETED BY SENIOR INSTITUTIONAL OFFICIAL (i.e. Dept Chairman, Dean, etc)

This is to recommend the applicant for an Externship at the Shaukat Khanum Memorial Cancer Hospital
and Research Centre for the above dates. This certifies that the applicant is in good academic standing at
our institution and that the information supplied here is complete and accurate, to the best of my
knowledge.
NAME ________________________________________ DATE: _______________
ADDRESS: ________________________________________________
SIGNATURE & STAMP: ______________

INSTRUCTIONS

Please attach your relevant documents (diplomas, certificates etc)

Please bring your latest photograph at the time of joining

Application Fee (non-refundable) to be submitted with the application

Domestic applicants: Pakistan Rupees Rs. 1,500 Payment, can be made by bank draft or
cheque made payable to "SHAUKAT KHANUM MEMORIAL TRUST"

International applicants: Pounds Sterling 75, or USDollars $150 as a bank

draft payable to SHAUKAT KHANUM MEMORIAL TRUST"

Send your completed application to

EXTERNAL ELECTIVE OFFICE
SKMCH&RC, 7A, Block R3 Johar Town, Lahore, Pakistan
Tel: +92 42 5945100 Ext 2524;
UAN: 111-155 -555
Fax: +92-42-5945207

HRD/TR/R/05