Form No: 2023-S22122 Workshop Registration Form Application Date: 16-01-2023
Full Name: NAEEM UR REHMAN MIR
Father's Name: SHAHID PERVIZ MIR
New NIC: 34603-8639095-5
Date of Birth: 1982-12-10
Gender/Marital Status: Male / Married
Email: drnaeemmir@[Link]
Institute Information
Fellow Ship #: CRD-19-24592 CPSP ID: 2010-2662
Program: FCPS Speciality: CARDIOLOGY
Country/State/City: Pakistan, Punjab, Wazirabad
Institute: WAZIRABAD INSTITUTE OF CARDIOLOGY
Unit/Department: Chaudhary Pervaiz Elahi Institute of Cardiology, Wazirabad - Cardiology Department
Workshop(s) Details
# Workshop Name Center
1 Assessment of Competence LAHORE
2 Educational Planning & Evaluation LAHORE
3 Research Methodology, Biostatistics & Medical Writing LAHORE
4 Supervisory Skills LAHORE
Present/Mailing Address (Residential Only)
Address: SHAANCO PRIVATE LIMITED, NEXT TO HAYEESON'S LEATHER FACTORY, GREEN TOWN, IN STREET
OPPOSITE TO OLD TELEPHONE EXCHANGE, PASRUR ROAD, SIALKOT CITY
Country/State/City: Sialkot, Punjab, Pakistan
Tel (Res.): 03157774331 Tel (Office): 03006105013
Cell: 03324584750 Postal Code: 51310
Permanent Address (Residential Only)
Address: SHAANCO PRIVATE LIMITED, NEXT TO HAYEESON'S LEATHER FACTORY, GREEN TOWN, IN STREET
OPPOSITE TO OLD TELEPHONE EXCHANGE, PASRUR ROAD, SIALKOT CITY
Country/State/City: Sialkot, Punjab, Pakistan
Tel (Res.): 03157774331 Tel (Office): 03006105013
Cell: 03324584750 Postal Code: 51310
Fee Information
Form Submission Center Lahore Transaction ID: 295501305141
Receipt #: LHR-O-23-4306 Receipt Date: 16-01-2023
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: 16-01-2023
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
College of Physicians and Surgeons Pakistan College of Physicians and Surgeons Pakistan
Debit/Credit Card Debit/Credit Card
Center: Lahore Fellow Ship #: CRD-19-24592 Center: Lahore Fellow Ship #: CRD-19-24592
Receipt #: LHR-O-23-4306 Date: 16-01-2023 Receipt #: LHR-O-23-4306 Date: 16-01-2023
Name: NAEEM UR REHMAN MIR Name: NAEEM UR REHMAN MIR
Trans ID: 295501305141 Approval Code: 249039 Trans ID: 295501305141 Approval Code: 249039
Form No: 2023-S22122 Form No: 2023-S22122
Fee Type Amount Fee Type Amount
W/S Fees - AOC PKR 8500.00 W/S Fees - AOC PKR 8500.00
W/S Fees - EP & EV PKR 8500.00 W/S Fees - EP & EV 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
Bank Services Charges PKR 1300.00 Bank Services Charges PKR 1300.00
Total: PKR 35300.00 Total: PKR 35300.00
Amount in words: Thirty-Five Thousand Three Hundred Only (PKR) Amount in words: Thirty-Five Thousand Three Hundred 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.
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