APPLICATION FORMINTERMEDIATE MODULE

OCTOBER 09, 2012

FRESH C

ANDIDATE

ALL ENTRIES TO BE MADE IN INK AND FILL ALL COLUMNS IN BLOCK LETTERS

Coloured, recent & alike

Passport Size Photograph( 5 x 6 cm)Pasted &

attested on front

YGDD=?= G>H@QKA;A9FK $KMJ?=GFKH9CAKL9F

7th Central Street, D.H.A. Phase II,Karachi-75500 (Pakistan)Tel: 99207100-10Fax: 99207120, 35881444UAN: 111-606-606E-mail: examinations@cpsp.edu.pkWeb-site: w w w . c p s p . e d u . p k

RTMC Registration No

Chosen Speciality for Examination

Chosen Centre of Examination

Date of Graduation Name of Institution No. & Date(According to MBBS/BDS Degree) of PMDC Registration

If Granted Exemption Letter No. SubjectDate of Exemption

Name (As per MBBS/BDS) Degree

Name of Father / Husband

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

Price Rs. 50/=IMMWEBCOPY

Anaesthesiology, Dentistry (Operative Dentistry), Dentistry (Oral & Maxillofacial Surgery), Dentistry (Orthodontics),

Dentistry (Prosthodontics) Diagnostic Radiology, Medicine, Obstetrics & Gynae, Ophthalmology, Otorhinolaryngology,

Paediatrics, Psychiatry, Surgery

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Amount No./Date Bank Branch

EXAMINATION FEE

Challan United Bank Ltd.

Bank Draft

Pay Order

PRESENT MAILING ADDRESS (Residential Only)

Date of Birth

--

DD MM YYYY

AREA CODE NO.

Marital Status Married Single

Nationality Sex Male Female

City Country

C.N.I.C

Tel (Res) AREA CODE NO.Office .ONEDOCCell Email

PERMANENT ADDRESS (If different from above)

--

--

--

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

-

-

City Country

Candidates who qualify in Theory examination can appear in three out of four consecutive TOACS examinations(including missed chances) without appearing in theory examination again.

A candidate who does not appear in the immediate following TOACS examination after passing theory examination willlose one chance. Only two of three consecutive chances will be available to such candidates.

Theory examination is conducted at Karachi, Hyderabad, Quetta, Multan, Lahore, Faisalabad, Rawalpindi, Bahawalpur,Islamabad, Peshawar, Larkana, Abbottabad, Nawabshah. The College can hold theory and TOACS examination in one ormore cities of the country depending on the number of candidates and logistic facilities available in a city irrespective ofthe choice given in the Box above.

SUPERVISOR DETAILS

Name:

Designation & Name of Institution

RTMC Registration No.

For Candidates appearing in IMM Surgery/Medicine

Will Continue for FCPS in same subject Yes No Will Continue in

MMI gnissap retfa ytilaicepS buS

Note: All candidates are required to mention valid E-mail address for correspondance. ExaminationDepartment will communicate Significant / Urgent correspondance through E-mail address only.

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DECLARATION BY CANDIDATE

I, Dr.

S/o D/o W/o

Do solemnly declare that all the information provided above is correct. Incorrect information maylead to cancellation of enrollment / admission / results and disciplinary action.

DD MM YYYY

DATE SIGNATURE OF CANDIDATE

PRESENT EMPLOYMENT STATUS(Tick Mark Appropriate Box)

Employed Self Employed

If employed:

Designation

Name of Institution

Address of Institution

Name of Immediate Supervising Officer

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 / HEAD OF INSTITUTION

SUPERVISOR

Name:

SignatureStamp

HEAD OF INSTITUTION (M.S. , Dean, Assoc. Dean, Comandant, Principal)

Name:

SignatureStamp

Please note that certificates verifying the completion of required training, upto atleast one month before the date ofexamination i.e. September 09, 2012 and should be submitted with this application. No relaxation in the training willbe allowed.

INCOMPLETE APPLICATION WILL NOT BE PROCESSED

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FOR OFFICE USE ONLY

DD MM YYYY

DATEReceipt No.

Processed by

Name

Checked by

Rechecked by

Coloured, recent & alike

Passport Size Photograph( 5 x 6 cm)

ATTESTEDon back

indicating name of candidate in

CAPITAL LETTERS& stapled

Coloured, recent & alike

Passport Size Photograph( 5 x 6 cm)

ATTESTEDon back

indicating name of candidate in

CAPITAL LETTERS& stapled

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

The eligibility of the candidates shall be determined on the basis of documents submittedwith the application form which will be treated as final. Incomplete form will be rejected and nocorrespondence will be entertained after submission of application form.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, certificates duly signed by approved supervisors and countersigned by Head of Institution and copy of RTMC Registration Certificate.

RTMC Registration Certificate (for all registered training programmes)RTMC acknowledgment certificate of elective rotationCertificate of passing FCPS Part-I/Exemption letter from CPSPOptic Refraction Module certificate for Ophthalmology candidates onlyAll candidates have to submit a certificate of attendance of the required mandatory workshopsalong with application form for examination.a) Computer & Internet Orientation.b) 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, including

Ophthalmology, Obstetrics & Gynaecology). Computerised National Identity Card

MBBS Degree

Valid PMDC Registration CertificateThree coloured photographs taken recently and of prescribed size (5cm x 6 cm). One to be pasted inthe box on each form and got attested on front. Other photographs be stapled in the box provided in the application and enrolment forms. These photographs should indicate name of candidate in capital lettersand attested on the back.Evidence of having paid examination fee (original Bank Draft /Pay Order).Log Book (Prescribed by CPSP)

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

54

32.9

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

T h i s P a g e t o b e r e t a i n e d b y t h e c a n d i d a t e

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CHECK LIST FOR FRESH / REPEATER CANDIDATES (as applicable)

The eligibility of the candidate shall be determined on the basis of documents submitted with theapplication form which will be treated as final. Incomplete form will be rejected and nocorrespondence will be entertained after submission of application form.

Following are the documents required to process application form for IMM examination. Please check( ) the appropriate box or . Explanation must be given on a separate page, if you havechecked ( ) to any of the documents.

1. Letter of passing FCPS-I (letter of congratulation)

2. Certificate of residency training with complete detail of rotation as prescribed in the relevant prospectus. On institution’s letterhead signed by supervisor, HOD and HOI (M.S., Dean, Assoc. Dean, Comandant, Principal) clearly mentioning dates of training, reference number, date of issue with official seal.

3. RTMC registration certificate for registered training 4. RTMC acknowledgement certificate for elective rotations 5. Appointment order and joining report of training, including rotations. (as applicable)

6. Passing certificate of Optic Refraction Module (Ophthalmology Candidate)

7. Certificate of attendance of mandatory workshops (as applicable)

i. Introduction to Computer and Internet ii. Research Methodology Biostatics and Dissertation (Irrespective of the approval of dissertation)

iii. Communication Skills iv. Basic Surgical Skills (For candidates appearing in Surgery & Allied subjects)

8. Computerized National Identity Card

9. M.B.B.S degree

10. Valid PMDC registration certificate

11. Three coloured recent & alike photographs (5cm X 6cm) One to be attested on front & remaining on the back.

12. Evidence of having paid examination fee (original bank draft/pay order. Bank Challan (Amount, No. and Date)

Postal order are not accepted)

13. Log Book prescribed by CPSP (as applicable) complete in all respect duly

signed by Supervisor.14. Any other document which needs to be submitted with this application form (give detials)

Candidates must submit this sheet along with application formNote: All the Photocopies must be attested. Attestation must be stamped with name and

designation of the attester by one of the following. Fellow of CPSP with his Fellowship number Principal / Professor of Medical College/Postgraduate Medical InstituteMedical Superintendent / Head of the Medical Institution

YES NO.

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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 / BDS DEGREE

5. P.M.D.C. REG. (VALID)

6. C.N.I.C

7. WORKSHOPS CERTIFICATE

a) Research, Biostatistics

b) Comp / Internet

c) Communication Skills

d) Surgical Skills

8. TRAINING PROFORMA

a) R.T.M.C Registration

b) Appointment order / Letter

c) Experience / Residency Certificate

d) R.T.M.C A-Card of Elective Rotations

9. LAST EXAM RESULT LETTER FOR FCPS-II REPEATER CANDIDATE

10. LOG BOOK

YES NO.

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EXAM: I.M.M SUBJECT: