Form No: 2023-109972 Workshop Registration Form Application Date: 22-05-2023

Full Name: NIGHAT JAHAN

Father's Name: ALI MADAD
New NIC: 71501-4772553-8
Date of Birth: 1993-03-01
Gender/Marital Status: Female / Single
Email: nighatjahan536@gmail.com Qualification Type: MBBS

Registration Information
Program: FCPS Speciality: OBSTETRICS AND GYNAECOLOGY
Country/State/City: Pakistan, Punjab, Islamabad
Institute: SHAHEED ZULFIQAR ALI BHUTTO MEDICAL UNIVERSITY/PIMS
Supervisor: KAUSAR MASOOM Unit/Department: 2
RTMC #: OBG-2019-042-9517 CPSP ID: 2019-3960

Workshop(s) Details
# Workshop Name Center

1 Communication Skills ISLAMABAD

2 Introduction to Computer & Internet ISLAMABAD
3 Primary Surgical Skills ISLAMABAD
4 Research Methodology, Biostatistics & Dissertation Writing ISLAMABAD

Present/Mailing Address (Residential Only)

Address: HOUSE NO181 STREET 33 G8B ISLAMABAD
Country/State/City: Islamabad, Punjab, Pakistan
Tel (Res.): 03129705908 (Father) Tel (Office):
Cell: 03325921239 Postal Code: 92

Permanent Address (Residential Only)

Address: HOUSE 181 STREET 33 G9 ISLAMABAD
Country/State/City: Islamabad, Punjab, Pakistan
Tel (Res.): 03129705908 (Father) Tel (Office):
Cell: 03325921239 Postal Code: 92

Fee Information
Fee Type: Bank Challan Center: Islamabad
Currency: PKR Amount: 8000
Receipt #: ISL-C-23-10166 Receipt Date: 22-05-2023
Bank Name: Meezan Bank Ltd.
Branch Name: Tooba Masjid Branch

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

Disclosure Information
The activity does not have any commercial support, and its organizers, planners and speakers do not have any relevant financial relationship.

Signature of Candidate: ________________________________ Dated: 22-05-2023

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 - Applicant

Branch: Tooba Masjid Branch Customer Code: CPSP Branch: Tooba Masjid Branch Customer Code: CPSP

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

DME DME
Cash Deposit Bank Challan Cash Deposit Bank Challan
Fee can be paid in any Meezan branch in Pakistan Fee can be paid in any Meezan branch in Pakistan
(Via Utility Bill Collection Menu) - Use Receipt # to get the data (Via Utility Bill Collection Menu) - Use Receipt # to get the data

Center: Islamabad CPSP ID: 2019-3960 Center: Islamabad CPSP ID: 2019-3960

Receipt #: ISL-C-23-10166 Receipt Date: 22-05-2023 Receipt #: ISL-C-23-10166 Receipt Date: 22-05-2023

Name: NIGHAT JAHAN Name: NIGHAT JAHAN

Form No: 2023-109972 Form No: 2023-109972

Fee Type Amount Fee Type Amount

W/S Fees - Communication PKR 2000.00 W/S Fees - Communication PKR 2000.00

W/S Fees - I.T. Workshop PKR 2000.00 W/S Fees - I.T. Workshop PKR 2000.00

W/S Fees - Surgical Skills PKR 2000.00 W/S Fees - Surgical Skills PKR 2000.00

W/S Fees - RMBDW PKR 2000.00 W/S Fees - RMBDW PKR 2000.00

Total: PKR 8000.00 Total: PKR 8000.00

Amount in words: Eight Thousand Only (PKR) Amount in words: Eight Thousand Only (PKR)

____________________________ ____________________________ ____________________________ ____________________________

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

Contact No: ________________ Contact No: ________________

Note: Depositer/candidate must ensure that bank stamp is readable and signed. Note: Depositer/candidate must ensure that bank stamp is readable and signed.
Note: The amount of fee applicable at the time of depositing the challan by the candidate will Note: The amount of fee applicable at the time of depositing the challan by the candidate will
be send to Meezan bank through API by CPSP. be send to Meezan bank through API by CPSP.
page 2 / 4
 TRIPLICATE - CPSP Finance QUADRUPLICATE - Bank

Branch: Tooba Masjid Branch Customer Code: CPSP Branch: Tooba Masjid Branch Customer Code: CPSP

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

DME DME
Cash Deposit Bank Challan Cash Deposit Bank Challan
Fee can be paid in any Meezan branch in Pakistan Fee can be paid in any Meezan branch in Pakistan
(Via Utility Bill Collection Menu) - Use Receipt # to get the data (Via Utility Bill Collection Menu) - Use Receipt # to get the data

Center: Islamabad CPSP ID: 2019-3960 Center: Islamabad CPSP ID: 2019-3960

Receipt #: ISL-C-23-10166 Receipt Date: 22-05-2023 Receipt #: ISL-C-23-10166 Receipt Date: 22-05-2023

Name: NIGHAT JAHAN Name: NIGHAT JAHAN

Form No: 2023-109972 Form No: 2023-109972

Fee Type Amount Fee Type Amount

W/S Fees - Communication PKR 2000.00 W/S Fees - Communication PKR 2000.00

W/S Fees - I.T. Workshop PKR 2000.00 W/S Fees - I.T. Workshop PKR 2000.00

W/S Fees - Surgical Skills PKR 2000.00 W/S Fees - Surgical Skills PKR 2000.00

W/S Fees - RMBDW PKR 2000.00 W/S Fees - RMBDW PKR 2000.00

Total: PKR 8000.00 Total: PKR 8000.00

Amount in words: Eight Thousand Only (PKR) Amount in words: Eight Thousand Only (PKR)

____________________________ ____________________________ ____________________________ ____________________________

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

Contact No: ________________ Contact No: ________________

page 3 / 4
Note: Depositer/candidate must ensure that bank stamp is readable and signed. Note: Depositer/candidate must ensure that bank stamp is readable and signed.
Note: The amount of fee applicable at the time of depositing the challan by the candidate will Note: The amount of fee applicable at the time of depositing the challan by the candidate will
be send to Meezan bank through API by CPSP. be send to Meezan bank through API by CPSP.

page 4 / 4