application form fcps - ii examination · f. fcps - ii (ksa) med, obs & gyn, surg, paed &...

F. FCPS - II (KSA) Med, OBS & GYN, Surg, Paed & Ophth (f.b@b@r) “1” 24211

AAPPPPLLIICCAATTIIOONN FFOORRMMFCPS - II EXAMINATION

JULY 27, 2011

FRES

H CAND

IDATE

S ONL

Y

APPEA

RING IN

SAUDI A

RABIA

AT RIY

ADH

ALL ENTRIES TO BE MADE IN INK AND IN BLOCK LETTERS

Passport Size Photograph( 5 x 6 cms)Pasted &

attested on front

Medicine, Obstetrics / Gynaecology,Surgery, Paediatrics & Ophthalmology

7th Central Street, D.H.A. Phase II,Karachi-75500 (Pakistan)Tel: 99207100-10Fax: 99207120, 35881444UAN: 111-606-606E-mail: [email protected]: w w w . c p s p . e d u . p k

RTMC Registration No.

PMDC Registration No.

Chosen Speciality for examination

Chosen centre for ClinicalExamination in Pakistan

Date of Passing FCPS -I Roll No. Subjectwith Enrollment No.

Date of Exemption, Letter No. Subjectif granted

According to MBBS Degree Name of Institution No. & date of PMDC Reg.Qualification with date of Graduation

Name (As per MBBS Degree)

Name of Father / Husband

SUPERVISOR’S DETAILS

Name:

Designation & Name of Institution

RTMC Registration No.

;ebb[][ e\H^oi_Y_Wdi $ Kkh][ediHWa_ijWd

APPEARED IN MCPS/DCPS EXAMINATION Yes ❑ No ❑

ROLL NO. DATE OF EXAM SUBJECT RESULTIf Yes, Give Details

WWEEBBCCOOPPYY

F. FCPS - II (KSA) Med, OBS & GYN, Surg, Paed & Ophth (f.b@b@r) “2” 24211 Page -2

No./Date Bank Branch

EXAMINATION FEE

Challan

Bank Draft

Pay Order

PRESENT MAILING ADDRESS (Residential)

Date of Birth

- -

DD MM YYYY

AREA CODE NO.

Martial Status Married ❑ Single ❑

Nationality Sex Male ❑ Female ❑

City Country

C.N.I.C

Tel. (Res.) AREA CODE NO.Office

CODE NO.Cell Email

PERMANENT ADDRESS (If different from above)

--

--

--

AREA CODE NO.Tel. (Res.) AREA CODE NO.Office --

--

City Country

A candidate who does not appear in TOACS / Clinical examination of the same session after passingtheory examination will lose one chance. Only two out of the next three consecutive chances will beavailable to such candidates.

★


DECLARATION BY CANDIDATE

I, Dr.

S/o D/o W/o

do hereby declare that information given above is correct to the best of my knowledge. Incorrectinformation may lead to cancelation of enrollment /admission /results and disciplinary action.

DD MM YYYY

DATE SIGNATURE OF CANDIDATE

We certify from personal knowledge and repute that

FULL NAME OF CANDIDATE _______________________________________________________

He/She has had successfully completed a period of training which complies with the ExaminationRegulations.

Is as regards character and professional conduct, a fit and proper person to be admitted as Fellow ofthe College of Physicians & Surgeons Pakistan.

2

1

CERTIFICATE OF SUPERVISOR AND HEAD OF INSTITUTION

SUPERVISOR

Name:

SignatureStamp

HEAD OF INSTITUTION

Name:

SignatureStamp

INCOMPLETE APPLICATION WILL NOT BE PROCESSED


FOR OFFICE USE ONLY

DD MM YYYY

DATEReceipt No.

Processed by

Name

Checked by

Rechecked by

PHOTOGRAPHPassport Size ( 5 x 6 cms)

ATTESTEDon back

indicating name of candidate in

CAPITAL LETTERS& stapled


ATTESTEDon back




ATTESTEDon back



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I N S T R U C T I O N S

The eligibility of the candidates shall be scrutinized on the basis of certificates of these requirementssubmitted with the application form which will be treated as final. The training (including rotations),should be completed one month before the date of theory examination.

Attested Photocopies to be enclosed

Certificates of residency training (including rotations) as per prospectus signed bysupervisor/countersigned by the Head of Unit/ Institution on the letterhead of the institute.

a) All the Training Certificates must be on proper letterheads of department / institutegiving dates of starting and ending residency training in each speciality / sub-specialityand stamped with official seal. Showing name of signing authority.

b) Only those certificates of residency and other certificates will be accepted by the Collegefor the purpose of eligibility, which will be issued by the Supervisor, Head of the Unit andcountersigned by Head of the recognized institution. Attention of the candidates is drawnto these requirements in the application form.

c) Provide documentary proof for all training claimed for fulfillment of requirementsincluding posting order, joining report, certificates duly signed by approved supervisorsand counter signed by Head of Institution and copy of RTMC Registration. (ANYENTRY WITHOUT DOCUMENTRY PROOF WILL BE REGECTED)

RTMC Registration Letter (for all registered training programmes)Certificate of passing FCPS Part-I/Exemption letter from CPSP

Certificate of approval of dissertation. (Issued by RTMC)

All fresh candidates have to submit a certificate of attendance of the required mandatoryworkshops: along with application forms

a) Computer & Internet Orientationb) Research Methodology, Biostatistics and Medical writing (irrespective of the approval of

dissertation)c) Communication Skills d) Basic Surgical Skillls (For candidates appearing in Surgery & Allied Subjects)

IMM pass certificate / MCPS diploma

Computerised National Identity Card

MBBS Degree

Valid PMDC Registration Certificate

Seven coloured photographs taken recently and of prescribed size (5cm x 6 cm). One to bepasted in the box on each form and got attested on front. Other photographs be stapled in the boxprovided in the application and enrolment forms. These photographs should indicate name ofcandidate in capital letters and attested on the back.

Evidence of having paid examination fee (original Bank Draft /Pay Order)

Log Book (Prescribed by CPSP)

Note: a) Admit cards issued to eligible candidates must be kept carefully as this has to be returned withthe repeater’s application form. If this is not submitted penalty could be imposed.

b) Training must have been completed one month before the date of theory examination i.e. by June 26, 2011.

43

2.10

2.9

2.8

2.7

2.6

2.5

2.4

2.3

2.2

2.1

2

1

All attestation must be stamped with name and designation of the attester by ONE of the following

☛☛ Fellow of the College of Physicians & Surgeons Pakistan with his Fellowship Number.

☛☛ Principal/Professor of Medical Colleges/Postgraduate Medical Institutions.

☛☛ Medical Superintendent / Head of the Medical Institution.

LIST OF DOCUMENTS REQUIRED TO BE ENCLOSED WITH THE APPLICATION FORM


PLEASE SUBMIT YOUR DOCUMENTS IN FOLLOWING SEQUENCE

1. BANK DRAFT / RECEIPT / CHALLAN (EXAM FEE) ❑ ❑

2. APPLICATION FORM ❑ ❑

3. FCPS-1 PASSED / EXEMPTED LETTER ❑ ❑

4. MBBS DEGREE ❑ ❑

5. P.M.D.C. REG. (VALID) ❑ ❑

6. IMM pass certificate / MCPS diploma ❑ ❑

7. C.N.I.C ❑ ❑

8. WORKSHOPS CERTIFICATE

a) Research, Biostatistics ❑ ❑

b) Computer / Internet ❑ ❑

c) Communication Skills ❑ ❑

d) Surgical Skills ❑ ❑

9. OPTICS & REFRACTION ❑ ❑

10. DISSERTATION APPROVAL CERTIFICATE ❑ ❑

11. TRAINING PERFORMA ❑ ❑

12. RTMC REGISTRATION CERTIFICATE ❑ ❑

13. DATE WISE EXPERIENCE CERTIFICATE ❑ ❑

14. APPOINTMENT LETTER / JOINING REPORT ❑ ❑

15. LOG BOOK ❑ ❑

YES NO.

EXAM: FCPS-II SUBJECT:

application form fcps - ii examination · f. fcps - ii (ksa) med, obs & gyn, surg, paed &...

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