THE AGA KHAN UNIVERSITY

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Residency Programme Application Form

Instructions for completing the application: 1. Complete the application form in bold letters or type. 2. The application form should be attested by a supervising consultant, the Principal of the Institute last worked at or a Professor of any medical college.

3. Application fee and deadlines Early bird registration (all programmes): Last Date: Registration Fee: Friday July, 19, 2013, 4 pm Rs. 2,500/-

Registration deadline after July 19, 2013 (for all programmes)

Thursday August 1, 2013 Registration Fee: Rs.5,000/-

The completed application form along with required documents must be received in the Medical College Admission Office, Aga Khan University between 9:00 am - 12:00 noon.

Please note - Incomplete application forms will not be processed. - Please specifiy only one residency programmes from the following: 3-year programmes Adult Cardiology Clinical Haematology Dermatology Gastroenterology Nephrology Neurology Pulmonary Medicine Pulmonary Medicine 4-year programmes Cardiothoracic Surgery Community Medicine Emergency Medicine Family Medicine Internal Medicine Neurosurgery Obstetrics & Gynaecology Operative Dentistry Ophthalmology Orthodontics Orthopaedic Surgery Paediatrics & Child Health Paediatric Surgery Plastic Surgery Psychiatry Radiation Oncology Urology 5-year programmes Anaesthesiology Chemical Pathology Diagnostic Radiology General Surgery Haematology Histopathology Microbiology Otolaryngology/Head & Neck Surgery

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THE AGA KHAN UNIVERSITY

Residency Programme Application Form
Registration No. Regular Registration Rs. 5,000/-

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Date of Application: _________________________ Early Bird Rs. 2,500/-

Please ensure to include the following items: [ ] Completed application form endorsed by relevant authority. Please paste recent [ ] Attested copies of mark sheets of all professional examinations. photograph attested [ ] Attested copy of MBBS degree. on the front [ ] Attested copy of valid PMDC registration. (but not on face) [ ] Attested copy of one year internship/house job certificate. [ ] Attested copy of FCPS Part I certificate, if applicable . NOTE: All photocopies should be cut or minimised to A4. [ ] Copy of National Identity Card / Passport. (Page 1&2) [ ] Two passport size photographs: taken one week prior to submission of this application. one attested and pasted on this application form and the other attested at the back for the Admit Card. Face should be clearly visible. [ ] Self-addressed envelope (4.5 x 8.5 inches). APPLICATION FOR RESIDENCY IN : (name of specialty)
(No change in specialty allowed as per CPSP guidelines)

Name (as per CNIC) Gender M F Mailing Address Date of Birth

Father/Spouse name Nationality CNIC / Passport #

Email Permanent Address (if different from mailing address)

Cell #

Fax #

Home / Office Tel # Name of medical college attended Medical college graduation Month Year

Details of any supplementary exams Name and address of institution where house job was completed Year of house job completion Cleared FCPS - I Other experience Admission Test Centre (Select [ Is your application complete? ] one) Yes [ ] Karachi No [ ] Hyderabad Rawalpindi Yes [ ] No [ ] If yes, specify year

If no, state pending documents

Endorsement (should be attested by the Principal of the institute last worked at or professor of any medical college) I certify that the information given above is correct. Name and Designation Official: Please do not write in this space Complete [ ] Incomplete [ ] Dated: __________________________ Signature Official Stamp Date

Received by: ___________________

Recpt #_______________