DISCLOSURE FORM

CONSENT TO RELEASE OF INFORMATION

TO THE NATIONAL MEDICAL AUTHORITY, PAKISTAN MEDICAL COMMISSION

I…………………………………..………………..(full name) hereby authorize the National Medical Authority

of the Pakistan Medical Commission (PMC), to obtain verification and all necessary information
for purposes of verification of my credentials from the granting institution/authority or any
other authority as the case may be.

I shall directly pay to the institution/authority the fee, if any, that may be charged for
verification by the institution/authority who is requested to provide the verification provider.

The National Medical Authority of the Pakistan Medical Commission is not bound to any
confidentiality in respect of verification and information received by it in pursuance of my
request.

SIGNATURE OF APPLICANT/DOCTOR