Application Form for Internship Programme - Aga Khan University
Application Form for Internship Programme - Aga Khan University
Application Form for Internship Programme - Aga Khan University
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
INTERNSHIP<br />
2014<br />
THE AGA KHAN UNIVERSITY<br />
<strong>Internship</strong> <strong>Programme</strong> <strong>Application</strong> <strong>Form</strong><br />
Date of <strong>Application</strong>: _________________________<br />
Early Bird † Rs. 2,500/- Regular Registration Rs. 5,000/- †<br />
Registration No.<br />
Following items are to be included with this application:<br />
[ ] Completed application <strong>for</strong>m endorsed by supervisor/principal.<br />
[ ] Attested copies of mark sheets of all professional examinations.<br />
[ ] Attested copy of MBBS degree.<br />
[ ] Attested copy of provisional registration of PMDC.<br />
NOTE: All photocopies should be cut or minimised to A4<br />
[ ] Two passport size photographs: taken one week prior to submission of this application.<br />
1 -<br />
Please leave blank<br />
one attested and pasted on this application <strong>for</strong>m and the other attested at the back <strong>for</strong> the Admit Card. Face should be clearly visible<br />
[ ] Copy of National Identity Card / Passport (page 1 & 2).<br />
[ ] Self-addressed envelope (4.5 x 8.5 inches).<br />
0<br />
Please paste recent<br />
photograph attested<br />
on the front<br />
(but not on face)<br />
Name<br />
(as per CNIC)<br />
Father/Spouse name<br />
Gender M F Date of Birth Nationality CNIC / Passport #<br />
Mailing Address<br />
Email Cell # Fax #<br />
Permanent Address (if different from mailing address)<br />
Home / Office Tel #<br />
Name of medical college attended<br />
Medical college graduation Month Year<br />
Details of any supplementary exams<br />
Professional Exams<br />
Aggregate Marks<br />
Professional Exams<br />
Aggregate Marks<br />
1st Professional<br />
3rd Professional<br />
2nd Professional<br />
4th Professional<br />
Any other Clinical experience Yes (please provide detail in one line below) No<br />
Admission Test Centre (Select [ ] one) Karachi Hyderabad Rawalpindi<br />
Is your application complete? Yes [ ] No [ ] If no, state pending documents<br />
Endorsement (should be attested by the Principal of the institute last worked at or professor of any medical college)<br />
I certify that the in<strong>for</strong>mation given above is correct.<br />
Name and Designation<br />
Signature<br />
Official Stamp<br />
Date<br />
Official: Please do not write in this space<br />
Complete [ ] Incomplete [ ]<br />
Received by: ___________________<br />
Dated: __________________________ Recpt#___________________
Change language