Form No: 2022-S16116 Workshop Registration Form Application Date: 09-02-2022

Full Name: SUBHAN ULLAH

Father's Name: SANA ULLAH
New NIC: 33303-0950101-3
Date of Birth: 19-01-1981
Gender/Marital Status: Male / Married
Email: drsubhan786@hotmail.com

Institute Information
Fellow Ship #: PSY-17-20140 CPSP ID: 2011-1837
Program: FCPS Speciality: PSYCHIATRY
Country/State/City: Pakistan, Punjab, Faisalabad
Institute: FAISALABAD MEDICAL UNIVERSITY & AFFILIATED HOSPITALS
Unit/Department:

Workshop(s) Details
# Workshop Name Center

1 Assessment of Competence FAISALABAD

2 Research Methodology, Biostatistics & Medical Writing FAISALABAD
3 Supervisory Skills FAISALABAD

Present/Mailing Address (Residential Only)

Address: HOUSE # P397 STREET ANSARIAH NEAR TELEPHONE EXCHANGE TOBA
Country/State/City: Toba Tek Singh, Punjab, Pakistan
Tel (Res.): 046-2515269 Tel (Office): 03004489579
Cell: 03214201963 Postal Code:

Permanent Address (Residential Only)

Address: HOUSE # P397 STREET ANSARIAH NEAR TELEPHONE EXCHANGE TOBA
Country/State/City: Toba Tek Singh, Punjab, Pakistan
Tel (Res.): 046-2515269 Tel (Office): 03004489579
Cell: 03214201963 Postal Code:

Fee Information
Fee Type: Bank Challan Center: Faisalabad
Currency: PKR Amount: 25500
Receipt #: FSL-C-22-1617 Receipt Date: 09-02-2022
Bank Name: UNITED BANK LTD
Branch Name: Sunset Boulevard Branch, Karachi (1620)

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: 09-02-2022

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: Sunset Boulevard Branch, Karachi (1620) Account #: 277409209 Branch: Sunset Boulevard Branch, Karachi (1620) Account #: 277409209

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 UBL branch in Pakistan Fee can be paid in any UBL branch in Pakistan

Center: Faisalabad Fellow Ship #: PSY-17-20140 Center: Faisalabad Fellow Ship #: PSY-17-20140

Receipt #: FSL-C-22-1617 Receipt Date: 09-02-2022 Receipt #: FSL-C-22-1617 Receipt Date: 09-02-2022

Name: SUBHAN ULLAH Name: SUBHAN ULLAH

Form No: 2022-S16116 Form No: 2022-S16116

Fee Type Amount Fee Type Amount

W/S Fees - AOC PKR 8500.00 W/S Fees - AOC PKR 8500.00

W/S Fees - RMBMW PKR 8500.00 W/S Fees - RMBMW PKR 8500.00

W/S Fees - Supervisory Skills PKR 8500.00 W/S Fees - Supervisory Skills PKR 8500.00

Total: PKR 25500.00 Total: PKR 25500.00

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

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 TRIPLICATE - CPSP Finance QUADRUPLICATE - Bank

Branch: Sunset Boulevard Branch, Karachi (1620) Account #: 277409209 Branch: Sunset Boulevard Branch, Karachi (1620) Account #: 277409209

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 UBL branch in Pakistan Fee can be paid in any UBL branch in Pakistan

Center: Faisalabad Fellow Ship #: PSY-17-20140 Center: Faisalabad Fellow Ship #: PSY-17-20140

Receipt #: FSL-C-22-1617 Receipt Date: 09-02-2022 Receipt #: FSL-C-22-1617 Receipt Date: 09-02-2022

Name: SUBHAN ULLAH Name: SUBHAN ULLAH

Form No: 2022-S16116 Form No: 2022-S16116

Fee Type Amount Fee Type Amount

W/S Fees - AOC PKR 8500.00 W/S Fees - AOC PKR 8500.00

W/S Fees - RMBMW PKR 8500.00 W/S Fees - RMBMW PKR 8500.00

W/S Fees - Supervisory Skills PKR 8500.00 W/S Fees - Supervisory Skills PKR 8500.00

Total: PKR 25500.00 Total: PKR 25500.00

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

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