POSTGRADUATE MEDICAL INSTITUTE Attach Photograph here

HAYATABAD PHASE-IV, PESHAWAR (PAKISTAN) (Put Name and

Attestation at the back)
APPLICATION FORM FOR ADMISSION IN
MCPS TWO YEAR TRAINING PROGRAM
www.pgmi.edu.pk

Instructions to fill the form:

1. Fill the Application Form using Microsoft word.

2. Do not leave any column blank, if Not Applicable please write “N/A”.
3. Do not overwrite or cross any information on the form.
4. Attach photocopies of all educational testimonials with the form.
5. An amount of Rs. 3000/- as application processing fee (non refundable) may be deposited on the prescribed
deposit slip in the PGMI’s A/C No. 0653915911004179 in MCB Bank Limited, Hayatabad Branch (Branch
Code: 1448) Phase-IV New Pakistan Tobaco Board,Peshawar.

Eligibility Criteria

a Have you done One Year House Job and Testimonials are available. Yes No

b Do you have a “VALID” PM&DC’s Full Registration i.e. License to Practice Yes No

If No in case of a and b then you are not eligible.

Personal Details

Full Name: MARYAM TAHIR

(As given in Computerized National Identity Card)

Father’s Name: DR. TAHIR NADEEM KHAN

Applicant’s CNIC: 17301-6043667-8 (Attach Attested Photocopy of CNIC)

Date of Birth: 23 08 1992 Gender: Male Female

Day Month Year

Phone No. 091-5828639 Mobile No. 0307-8059598 Email Address. maryam.bds@gmail.com

Domicile D.I.KHAN Domicile of Spouse (Only for Female Candidates) N/A

Nationality (Foreign Students Only) N/A Valid Study Visa Duration N/A
Address
i) Postal Address (Where you want to receive letters from PGMI. N.B:- State your home address. Don’t give addresses of hostels):

_HOUSE NO.15, STREET NO. 2, SECTOR: J3, PHASE 2, HAYATABAD, PESHAWAR City_PESHAWAR

District/Agency/FR PESHAWAR Province KHYBER PAKHTUNKHWA___

ii) Permanent Address (if different from the above postal address): _VILLAGE KHANPUR SHUMALI, P.O. RANGPUR

SHUMALI, DERA ISMAIL KHAN City DERA ISMAIL KHAN

District/Agency/FR DERA ISMAIL KHAN Province: KHYBER PAKHTUNKHWA

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Admission Intension
I intend to get admission in Postgraduate (MCPS) program in the discipline / specialty and hospital given below:-
(State your options according to the Advertisement)

Specialty / Discipline PERIODONTICS Hospital KHYBER COLLEGE OF DENTISTRY

(Please note: It is not necessary to recommend the candidate for admission as per his/her choice. It depends on the
availability of seats in the Institutions/ hospitals and candidates merit. However, PGMI will provide an opportunity to the students
to secure an admission at any Public Sector Hospital subject to merit and availability of slots as per CPSP Criteria. Moreover, the
data obtained may also be used to analyze the trend of specialties selected by the candidates)

Details of Previous Postgraduate Trainings (if any)

Name of Department / Institution N/A
Name / Title of the Course / Training N/A
Discipline / Specialty N/A Name of Supervisor N/A
Date of Enrollment N/A RTMC No. (If applicable) N/A
Date of Leaving / Completion N/A Duration of Training Undertook N/A
Reason for leaving the training (if left uncompleted) N/A
(Note: Please attach copies of testimonials issued to you by your Institution in support of application)

To Be Filled by Already On-Job Candidates in Civil Service / Adhoc / Projects etc only
Name of Department / Institution N/A
Designation N/A Regular/AdHoc/Temporary N/A
Date of Appointment N/A
(Note: Please attach of proof regarding through proper channel apply or N.O.C)

Qualification Details
Specify whether you are an MBBS or a BDS :> BDS

Percentage
Professional Name of Institution / Year of Marks Total
/
Level College / University Passing obtained Marks
Attempts

1st Prof. PESHAWAR DENTAL 2012 372 700

53.14 / 2
(Part-I) COLLEGE
1st Prof. NIL NIL NIL NIL
NIL
(Part-II)
PESHAWAR DENTAL 2013 363 700
2nd Prof. 51.85 / 2
COLLEGE
PESHAWAR DENTAL 2014 498 800
3rd Prof. 62.25 / 1
COLLEGE
PESHAWAR DENTAL 2016 705 1200
Final Prof. 58.75 / 2
COLLEGE

Bank Slip Details

Original Bank Slip worth Rs. 3000/- vide No: Date: 20/04/2017

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 Check the list of documents to be attached with the application form:
 Three passport size recent photographs (Attested at the back)
 Rs. 3000/- origional bank receipt. (Photocopy of the bank receipt or any other form of payment is not
acceptable).
 DMCs for all professional MBBS / BDS Exams
 Academic Certificate showing attempts in each exam
 Domicile Certificate
 Applicant’s CNIC
 Applicant’s Domicile/Local Certificate
 One Year House Job Certificate
 Valid PMDC’s Full Registration Certificate
 Character Certificate
 Spouse’s Domicile/Local Certificate (only for female candidates)
 Through Proper Channel Apply / No Objection Certificate (in case of in-service candidates)

Undertaking by Applicant:
I solemnly verify that the particulars stated above are correct to the best of my knowledge and belief. In case
any discrepancy is identified by PGMI at any stage, my training shall be immediately terminated and I will have
no right of appeal or seek relief from court of law. Consequently I'll be liable to pay back the entire amount,
released by PGMI included but not limited to monthly stipend or CPSP Mandatory Workshops.

Signature:

Deponent Name: MARYAM TAHIR

Date: 20/04/2017

NOTE:--
 The Application forms completed in all respect along with all the required documents should reache via
registered post or courier service or by hand by 21st April 2017 at address.
 Incomplete and delyaed applications (delivered after due date) will not be entertaiend. Moreover PGMI will
not be responsible for late delivery of application by courier services providors.

Dean
Postgraduate Medical Institute
Hayatabad Phase-IV Peshawar
Tel: 091-9217190

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 FOR BANK FOR APPLICANT / DEPOSITOR FOR TMO’s SECTION FOR ACCOUNT’s SECTION

Postgraduate Medical Institute Postgraduate Medical Institute Postgraduate Medical Institute Postgraduate Medical Institute
Hayatabad Peshawar Hayatabad Peshawar Hayatabad Peshawar Hayatabad Peshawar

No. _________ Date: ____________ No. _________ Date: ____________ No. _________ Date: ____________ No. _________ Date: ____________

MCB BANK LTD MCB BANK LTD MCB BANK LTD MCB BANK LTD
Hayatabad Branch (Br Code 1448) Peshawar Hayatabad Branch (Br Code 1448) Peshawar Hayatabad Branch (Br Code 1448) Peshawar Hayatabad Branch (Br Code 1448) Peshawar
Account No. 0653915911004179 Account No. 0653915911004179 Account No. 0653915911004179 Account No. 0653915911004179

Name of Depositor: Name of Depositor: Name of Depositor: Name of Depositor:

CNIC No. CNIC No. CNIC No. CNIC No.

Contact No. Contact No. Contact No. Contact No.

On Account of Application Processing On Account of Application Processing On Account of Application Processing On Account of Application Processing
Fee (MCPS Admission 2017-19) Fee (MCPS Admission 2017-19) Fee (MCPS Admission 2017-19) Fee (MCPS Admission 2017-19)

Rupees (In Figures) = Rs. 3,000/- Rupees (In Figures) = Rs. 3,000/- Rupees (In Figures) = Rs. 3,000/- Rupees (In Figures) = Rs. 3,000/-

Rupees (In Words) Three Thousand Rupees (In Words) Three Thousand Rupees (In Words) Three Thousand Rupees (In Words) Three Thousand
Only Only Only Only

______________________________ ______________________________ ______________________________ ______________________________

Depositor Sign Bank Officer Sign Depositor Sign Bank Officer Sign Depositor Sign Bank Officer Sign Depositor Sign Bank Officer Sign

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