Form No: 2019-9951 Course Registration Form Application Date: 10-05-2019

Full Name: SARA MALIK

Father's Name: MUHAMMAD FAYYAZ MALIK
New NIC: 37405-1720388-0
Date of Birth: 1987-01-21
Gender/Marital Status: Female / Single
Email: saramalik087@gmail.com

Registration Information
Program: FCPS Speciality: SURGERY
Country/State/City: Pakistan, Punjab, Rawalpindi
Institute: RAWALPINDI MEDICAL UNIVERSITY & ALLIED HOSPITALS
Supervisor: JAHANGIR SARWAR KHAN Unit/Department: HFH-1
RTMC #: SGR-2016-126-8070 CPSP ID: 2016-1879

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

1 Advance Trauma Life Support Provider Course ISLAMABAD January, 2020

Present/Mailing Address (Residential Only)

Address: CB-2324(430-B), BAHADUR KHAN STREET, SEHAM ROAD, PESHAWAR ROAD
Country/State/City: Rawalpindi Cantt., Punjab, Pakistan
Tel (Res.): 051-5480988 Tel (Office): 0515492979
Cell: 03368835508 Postal Code: 46000

Permanent Address (Residential Only)

Address: CB-2324(430-B), BAHADUR KHAN STREET, SEHAM ROAD, PESHAWAR ROAD
Country/State/City: Rawalpindi Cantt., Punjab, Pakistan
Tel (Res.): 051-5480988 Tel (Office): 0515492979
Cell: 03368835508 Postal Code: 46000

Fee Information
Fee Type: Bank Challan Fee Submission City: Islamabad
Currency: PKR Amount: 25000
Receipt #: ISL-C-19-4981 Receipt Date: 10-05-2019
Bank Name: UNITED BANK LTD
Branch Name: G-8, Al Markaz Branch, Islamabad (0234)

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: 10-05-2019

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.

page 1 / 3
 ORIGINAL - Concerned Department DUPLICATE - Applicant

Branch: G-8, Al Markaz Branch, Islamabad (0234) Account #: 010-2220-2 Branch: G-8, Al Markaz Branch, Islamabad (0234) Account #: 010-2220-2

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

ASD ASD
Bank Challan Bank Challan
Fee should be deposited in above mentioned branch. Fee should be deposited in above mentioned branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Islamabad CPSP ID: 2016-1879 Center: Islamabad CPSP ID: 2016-1879

Receipt #: ISL-C-19-4981 Receipt Date: 10-05-2019 Receipt #: ISL-C-19-4981 Receipt Date: 10-05-2019

Name: SARA MALIK Name: SARA MALIK

Form No: 2019-9951 Form No: 2019-9951

Fee Type Amount Fee Type Amount

Course Fee - ATLS PKR 25000.00 Course Fee - ATLS PKR 25000.00

Total: PKR 25000.00 Total: PKR 25000.00

Amount in words: Twenty-Five Thousand Only (PKR) Amount in words: Twenty-Five Thousand Only (PKR)

____________________________ ____________________________ ____________________________ ____________________________

Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature

Contact No: ________________ Contact No: ________________

page 2 / 3
 TRIPLICATE - CPSP Finance QUADRUPLICATE - Bank

Branch: G-8, Al Markaz Branch, Islamabad (0234) Account #: 010-2220-2 Branch: G-8, Al Markaz Branch, Islamabad (0234) Account #: 010-2220-2

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

ASD ASD
Bank Challan Bank Challan
Fee should be deposited in above mentioned branch. Fee should be deposited in above mentioned branch.
Challan not to be used for Online Fee Transfer. Challan not to be used for Online Fee Transfer.

Center: Islamabad CPSP ID: 2016-1879 Center: Islamabad CPSP ID: 2016-1879

Receipt #: ISL-C-19-4981 Receipt Date: 10-05-2019 Receipt #: ISL-C-19-4981 Receipt Date: 10-05-2019

Name: SARA MALIK Name: SARA MALIK

Form No: 2019-9951 Form No: 2019-9951

Fee Type Amount Fee Type Amount

Course Fee - ATLS PKR 25000.00 Course Fee - ATLS PKR 25000.00

Total: PKR 25000.00 Total: PKR 25000.00

Amount in words: Twenty-Five Thousand Only (PKR) Amount in words: Twenty-Five Thousand Only (PKR)

____________________________ ____________________________ ____________________________ ____________________________

Candidate / Depositor Signature Receiver's Signature Candidate / Depositor Signature Receiver's Signature

Contact No: ________________ Contact No: ________________

page 3 / 3