College of Physicians & Surgeons Pakistan Form No: CR-2021-1673

7th Central Street, Defence Housing Authority, Karachi -75500, Pakistan Date: 09-02-2021
Tel: 9207100-09 , Fax: 9207120, 5881444, UAN: 111-606-606
Website: www.cpsp.edu.pk

Change Request / Withdrawal Application (FCPS-I) Examination

Request: Change Subject

From Subject: COMMUNITY MEDICINE
To Subject: MEDICINE AND ALLIED
Term: 16-FEB-2021
Registration Type: Fresh
Examination Center: ISLAMABAD
Selected Speciality: COMMUNITY MEDICINE
Fee Type: Instrument (PO/DD/Cheque) Fee Amount
Form Submission Center Muzaffarabad
Receipt #: MUZ-I-21-134 Receipt Date: 09-02-2021
Number: 16940635 Date: 02/08/2021
Bank Name: United Bank Limited Bank City: Muzaffarabad
Branch Name: MAIN BAZAR CHATTAR AK (1106)

Profile Information
Medical Reg. No: 4124-AJK
Medical Reg. issue date: 04-01-2017 Medical Reg. expiry date: 31-12-2021
Full Name: HINA ASIF ABBASI
Father's name: MUHAMMAD ASIF ABBASI
Nationality: Pakistan Identity Card No: 81302-8270520-4
Gender: Female Marital Status: Single
Date of Birth: 29-10-2020
Email: azhar_gl@hotmail.com

Present/Mailing Address (Residential Only)

Address: C/O ANUM ASIF ABBASI,DIRECTOR ADMINISTRATION,AJK TEVTA UPPER CHATTER ,
Muzaffarabad, Azad Kashmir, Pakistan
Tel (Res.): 05822921547 Tel (Office):
Cell: 03481515505 Postal Code:

Permanent Address (Residential Only)

Same as Mailing Add: No
Address: C/O ANUM ASIF ABBASI,DIRECTOR ADMINISTRATION,AJK TEVTA UPPER CHATTER ,
Muzaffarabad, Azad Kashmir, Pakistan
Tel (Res.): 05822921547 Tel (Office):
Cell: 03481515505 Postal Code:

Professional Qualification
Degree: Passing Year:
Institute:
City/State/Country: ,,

Declaration
do hereby declare that information given 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: 09-02-2021

Note: Once entered in the application the center and subject will only be changed after submission of prescribed fee for this change.

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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

Change of Centre / Speciality Change of Centre / Speciality Change of Centre / Speciality

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: Muzaffarabad Center: Muzaffarabad Center: Muzaffarabad

Reg/Enrol No: 4124-AJK Reg/Enrol No: 4124-AJK Reg/Enrol No: 4124-AJK
Receipt #: MUZ-I-21-134 Date: 09-02-2021 Receipt #: MUZ-I-21-134 Date: 09-02-2021 Receipt #: MUZ-I-21-134 Date: 09-02-2021
Name: HINA ASIF ABBASI Name: HINA ASIF ABBASI Name: HINA ASIF ABBASI

PO/DD #: 16940635 Date: 02/08/2021 PO/DD #: 16940635 Date: 02/08/2021 PO/DD #: 16940635 Date: 02/08/2021
Bank Name: United Bank Limited Bank Name: United Bank Limited Bank Name: United Bank Limited
Branch: MAIN BAZAR CHATTAR AK (1106) Branch: MAIN BAZAR CHATTAR AK (1106) Branch: MAIN BAZAR CHATTAR AK (1106)
Branch City: Muzaffarabad Branch City: Muzaffarabad Branch City: Muzaffarabad
Form No: CR-2021-1673 Form No: CR-2021-1673 Form No: CR-2021-1673

Fee Type Term Amount Fee Type Term Amount

Change of FEB-2021 PKR 5000 Change of FEB-2021 PKR 5000

Centre/Speciality Fee Type Term Amount Centre/Speciality

Change of FEB-2021 PKR 5000

Centre/Speciality

Total: PKR 5000 Total: PKR 5000

Amount in words: Five Thousand Only Amount in words: Five Thousand Only
(PKR) Total: PKR 5000 (PKR)

Amount in words: Five 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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