DISCLOSURE FORM

CONSENT TO RELEASE OF INFORMATION

TO THE NATIONAL MEDICAL AUTHORITY, PAKISTAN MEDICAL COMMISSION

I ABEDULLAH KHAN 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