Form No: 2020-14778 Course Registration Form Application Date: 19-01-2020

Full Name: SAYYEDHA SIDRAH NISAR

Father's Name: MUHAMMAD NISAR KHAN
New NIC: 11101-2601163-0
Date of Birth: 01-04-1988
Gender/Marital Status: Female / Married
Email: sidrairfan17@yahoo.com

Registration Information
Program: FCPS Speciality: DIAGNOSTIC RADIOLOGY
Country/State/City: Pakistan, Punjab, Rawalpindi
Institute: MILITARY HOSPITAL
Supervisor: SAERAH IFFAT ZAFAR Unit/Department:
RTMC #: RAD-2019-124-2749 CPSP ID: 2019-62

Course(s) Details
# Course Name Center Expected Exam Date

1 Basic Life Support Provider Course ISLAMABAD December, 2020

Present/Mailing Address (Residential Only)

Address: FLAT E BLOCK D9 CMT GOLRA FLATS PESHAWAR ROAD RAWALPINDI
Country/State/City: Rawalpindi, Punjab, Pakistan
Tel (Res.): - Tel (Office):
Cell: 03324186798 Postal Code:

Permanent Address (Residential Only)

Address: FLAT E, BLOCK 53, LANE 4 ASKARI 7
Country/State/City: Rawalpindi, Punjab, Pakistan
Tel (Res.): - Tel (Office):
Cell: 03324186798 Postal Code:

Fee Information
Form Submission Center Rawalpindi Transaction ID: 220050576345
Receipt #: RWP-O-20-99 Receipt Date: 19-01-2020

Declaration
Above is correct to the best of my knowledge. Incorrect information may lead to cancelation of enrollment / admission / results and disciplinary action.

Signature of Candidate: ________________________________ Dated: 19-01-2020

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.

page 1 / 2
 ORIGINAL - Concerned Department DUPLICATE - Applicant

College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan

Debit/Credit Card Debit/Credit Card

Center: Rawalpindi CPSP ID: 2019-62 Center: Rawalpindi CPSP ID: 2019-62
Receipt #: RWP-O-20-99 Date: 19-01-2020 Receipt #: RWP-O-20-99 Date: 19-01-2020
Name: SAYYEDHA SIDRAH NISAR Name: SAYYEDHA SIDRAH NISAR
Trans ID: 220050576345 Approval Code: 406008 Trans ID: 220050576345 Approval Code: 406008

Form No: 2020-14778 Form No: 2020-14778

Fee Type Amount Fee Type Amount

Course Fee - BLS PKR 8000.00 Course Fee - BLS PKR 8000.00

Bank Services Charges PKR 280.00 Bank Services Charges PKR 280.00

Total: PKR 8280.00 Total: PKR 8280.00

Amount in words: Eight Thousand Two Hundred and Eigthy Only (PKR) Amount in words: Eight Thousand Two Hundred and Eigthy Only (PKR)

Note: Note:
In case of any refund/charge back against cards transaction through internet payment In case of any refund/charge back against cards transaction through internet payment
gateway, the candidate should claim the refund/charge back from CPSP directly. gateway, the candidate should claim the refund/charge back from CPSP directly.

page 2 / 2