Form No: 2019-10856 Course Registration Form Application Date: 03-07-2019

Full Name: ASSADULLAH

Father's Name: HAMZ ALI SOHU
New NIC: 43201-0417146-7
Date of Birth: 1988-07-01
Gender/Marital Status: Male / Single
Email: dr.assadullahsohu@hotmail.com

Registration Information
Program: MCPS Speciality: OTORHINOLARYNGOLOGY (E.N.T.)
Country/State/City: Pakistan, Punjab, Sahiwal
Institute: SAHIWAL MEDICAL COLLEGE/DHQ HOSPITAL
Supervisor: MUHAMMAD TARIQ Unit/Department:
RTMC #: ENT-2016-143-352 CPSP ID: 2016-4670

Course(s) Details
# Course Name Center Expected Exam Date

1 Basic Life Support Refresher Course LARKANA October, 2019

Present/Mailing Address (Residential Only)

Address: TO, HAMZA ALI SOHU. C/O ALI MURAD MEDICAL AND GENERAL STORE, OLD TANK CHOWK LARKANA.
Country/State/City: Larkana, Sindh, Pakistan
Tel (Res.): 03330331885 Tel (Office):
Cell: 03330331885 Postal Code:

Permanent Address (Residential Only)

Address: DR. ASSADULLAH, C/O PROF. AZEEM SOOMRA SB. GOVT. POST GRADUATE COLLEGE FOR BOYS
Country/State/City: Sahiwal, Punjab, Pakistan
Tel (Res.): 03008081614 Tel (Office):
Cell: 03008081614 Postal Code:

Fee Information
Fee Type: Pay Order/Demand Draft Form Submission Center: Larkana
Currency: PKR Amount: 4000
Pay Order/DD Number: 22421370 Pay Order/DD Date: 03-07-2019
Receipt #: LRK-I-19-966 Receipt Date: 03-07-2019
Bank Name: Habib Bank Limited Bank City: Rahim Yar Khan
Branch Name: sh. zayed medical college (2334)

Declaration
Above is correct to the best of my knowledge. Incorrect information may lead to cancelation of enrollment / admission / results and disciplinary action.

Signature of Candidate: ________________________________ Dated: 03-07-2019

Overwriting or electronic change is not allowed on the hard copy of this application form otherwise form may be rejected.
Candidates are advised to attach a hand written application if they want to change their particulars.

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 ORIGINAL - Concerned Department DUPLICATE - CPSP Finance TRIPLICATE - Applicant

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

ASD ASD ASD

Bank Instrument - Fee Receipt Bank Instrument - Fee Receipt Bank Instrument - Fee Receipt
(Pay Order/Demand Draft) (Pay Order/Demand Draft) (Pay Order/Demand Draft)

Center: Larkana CPSP ID 2016-4670 Center: Larkana CPSP ID 2016-4670 Center: Larkana CPSP ID 2016-4670
Receipt #: LRK-I-19-966 Date: 03-07-2019 Receipt #: LRK-I-19-966 Date: 03-07-2019 Receipt #: LRK-I-19-966 Date: 03-07-2019
Name: ASSADULLAH Name: ASSADULLAH Name: ASSADULLAH

PO/DD #: 22421370 Date: 03-07-2019 PO/DD #: 22421370 Date: 03-07-2019 PO/DD #: 22421370 Date: 03-07-2019
Bank Name: Habib Bank Limited Bank Name: Habib Bank Limited Bank Name: Habib Bank Limited
Branch: sh. zayed medical college (2334) Branch: sh. zayed medical college (2334) Branch: sh. zayed medical college (2334)
Branch City: Rahim Yar Khan Branch City: Rahim Yar Khan Branch City: Rahim Yar Khan
Form No: 2019-10856 Form No: 2019-10856 Form No: 2019-10856

Fee Type Amount Fee Type Amount

Course Fee - BLS PKR 4000.00 Course Fee - BLS PKR 4000.00
Fee Type Amount

Course Fee - BLS PKR 4000.00

Total: PKR 4000.00 Total: PKR 4000.00

Amount in words: Four Thousand Only (PKR) Amount in words: Four Thousand Only (PKR)
Total: PKR 4000.00

Amount in words: Four Thousand Only (PKR)

_________________________ _________________ _________________________ _________________

Candidate / Depositor Signature
Contact No: ________________
_________________________
Receiver's Signature
Candidate / Depositor Signature
Contact No: ________________
_________________
Candidate / Depositor Signature Receiver's Signature
Receiver's Signature
Contact No: ________________

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