CIVIL HOSPITAL BAHAWALPUR
AFFILIATED WITH QUAID-E-AZAM MEDICAL, BAHAWALPUR
SPECIALIZED HEALTHCARE & MEDICAL EDUCATION DEPARTMENT
Tel: 062-9239091, 062-2720235-36
_____ _____
For Official Use Only
APPLICATIONFORM File No: ………………………...
FOR THE POST OF MEDICAL OFFICER (M/F) Dated: ………………………….
IF APPLY AGAINST QUOTA PREF DATE OF
(PLEASE MENTION) SUBMISSION
PLEASE MENTION PREFERENCE DEPARTMENTS WHERE WANT TO APPLY (NOT MORE THEN 02):-
PREFERENCE (1)
PREFERENCE (2)
CANDIDATE NAME
FATHER’S NAME:
DATE OF BIRTH: AGE AT CLOSING DATE
GENDER RELIGION
NATIONALITY MARTIAL STATUS
1st ENTRY IN GOVT.SERVICE DOMICILE
PRESENT POSTING BPS
Regular/Contract/Adhoc/OPS Etc.
NATURE OF JOB
GRADUATION INSTITUTE COUNTRY
POSTGRADUATION INSTITUTE COUNTRY
PMDC# VALIDITY
MAILING ADDRESS
MOBILE # TEL(Res)
EMAIL
2
2. ACADEMIC QUALIFICATIONS:
Subject/ Result Date Exam Marks / %age Distinctions/
Certificate/Degree Institutions/ Country
Specialty Attempts Total Medal
Matric /SSC
Intermediate/HSS
PMDC Level – 1
MBBS,BDS etc.
PMDC Level-II a
Diploma etc.
(1 Years after Level 1)
PMDC Level- II b
M.Phil, MPH, MCPS etc.
(2Years after Level 1)
PMDC Level- III
FCPS, PhD, MD, MS, etc.
(4Years after Level I)
PMDC Level- IV
2nd Fellowship, D.Sc etc.
(2Years after Level III)
3. MBBS/BDS etc. (Details):
Ist Prof. Prat-I Ist Prof. Prat-II 2nd Prof. 3rd Prof. Final Prof. Total
(Obtain Marks (Obtain Marks (Obtain Marks (Obtain Marks (Obtain Marks (Obtain Marks /
/Total Marks) /Total Marks) /Total Marks) /Total Marks) /Total Marks) Total Marks)
Marks / Total
Attempt
Percentage
Distinctions/Medals
(Subject)
(Note: Please attach attempt certificates, Mark sheets & evidence of Distinctions & Medals).
4. POST GRADUATION (Details):
Post Graduation No. of Marks/Total, Positions/Medals
Institution Result Date
(Subject) Attempt(s) % if any
3
5. SERVICE RECORD:
Department/ Govt. / Duration
Post Held From To
Institution Private Y - M - D
6. EXPERIENCE:
Date of Appointment as MO/WMO/DEMOS etc: ___________________ Date of Post graduation: ____________________________
6 a. PRACTICAL EXPERIENCE (Before Post Graduation):
Post Held / Institution Duration
From To
Y - M - D
6 b. PRACTICAL EXPERIENCE (After Post Graduation):
Post Held / Institution Duration
From To
Y - M - D
4
7. TEACHING EXPERIENCE:
Post Held With Specialty Institution From To Duration
Senior Registrar
Assistant Professor
Associate Professor
Professor
Others
8. RESEARCH WORK AND PUBLICATIONS:
Journal reg. with Nature of Article Date of
Topic of Paper Name of Journal
PMDC Original/Review/ Publication
YES / NO Case Report
(Please attach extra sheet if required. Please attach evidence of the Journals Recognization by PMDC).
5
YES NO
• Are you an armed force released/retired personnel:
• Has your last service been terminated by government, for want of vacancy:
• Have you obtained the explicit permission of your present employer to apply for this post:
• Have you ever been dismissed/terminated/removed from any provincial/federal government /
autonomous/semi-autonomous organization:
• Do you require any time before joining this Institution, if selected; How much:
• Are you under liability to repay money to any institution or person, state the particulars and
also indicate the period for which you may be under bond to serve any institution:
• Have you any experience in your credit from a Private Hospital/ Institution in Pakistan:
• Have you any experience in your credit from a Hospital/ Institution of Foreign countries:
• Are you a Disabled person, if so, have you attached the disability certificate:
DECLARATION:
I do hereby solemnly declare that the information submitted by me in this application form is correct to
the best of my knowledge and belief. I fully understand that the facts given above will serve as the basis
for determination of my eligibility by the competent authority and my candidature so determined by the
competent authority will stand provisional until it is verified in the application form and is produced
after the closing date of submission of application form.
I also understand that if after the closing date for submission of application form my application is
found incomplete, wrongly filled in, unsigned or not accompanied by the attested copies of other
requisite documents, it will be liable to rejection, and that if any fact is concealed or miss-stated, in the
above replies, i am liable to be terminated automatically.
Dated: ____________________ ___________________________________
Candidate’s Signature:
6
CHECKLIST:
PLEASE ( ✓ ) TICK IN THE BOX OF “YES OR NO” AGAINST THE CERTIFICATES AND OTHER
DOCUMENTS WHICH YOU HAVE ATTACHED WITH THE APPLICATION FORM:
YES NO
MATRIC………..............................................................…………………….... ….…….
INTERMEDIATE……….……………………………………………………………..…..
MBBS/EQUIVALENT……………………………………………………………….….
HOUSE JOB CERTFICATE………………………………………………………….…
M. PHIL/PH.D/FCPS/EQUIVALENT …………………………………………………….
CERTIFICATE OF DISTINCTION/HONOUR, IF ANY………………………………...
RESEARCH PAPERS…………………………………………………………………...
EVIDENCE OF PMDC JOURNAL’S RECOGNITION………………………………..
CNIC……………………………………………………………………………………..
DOMICILE CERTIFICATE……………………………………………………………..
EXPERIENCE / SERVICE CERTIFICATE …………………………………………….
CERTIFICATE OF REGISTRATION WITH PMDC …………………………………….
IN CASE OF GOVT. SERVICE NOC CERTIFICATE…………….………………….….
IF APPLYING ON THE BASIS OF EQUIVALENT QUALIFICATION ………………
CERTIFICATE OF EQUIVALENCE BY THE PMDC
IF LAST SERVICE WAS TERMINATED FOR WANT OF VACANCY
CERTIFICATE OF SUCH SERVICE: ……………………………………………………
IN CASE OF EX-SERVICE MAN, DISCHARGE/RELEASE CERTIFICATE ……….
ANY OTHER DOCUMENTS ……………………………………………………….
