PM &DC. FORM.II I APPENDIX-5 REOUEST fOR RETENTIOi" Of NAME 0:'1 THE REGISTER OF MEDICAUDENTAL PRACTITIONERS TEL: 051-9106151-54, Website: ~w.pmdc This
'0fTI'"
UAN: 111.321-786, Fax 1"0.051.9106159 org.pk .Ii:.miu.l.;
[email protected]
can tie dOWflloaded
Please paste one Passport Size Photograph
Reac:e'.
from our •••• ebsite by uSing Ac"Obal
PI1010c0P~ 01 this form is also accepta:lle
=
PM DC Registration
The Registrar Pakistan Medical & Dental Council G.l0./4. Mauve Area, Islamabad.
No
Sir, It IS requested
lhat my name may please be retained on the register of the Cou~cil for a further period of five years.
am endosing ttle following documents:(If rtlt' rollo ••••. ln2 documenl. unllctinnrd.
C~~ 1. 2.
3. 4. 5. 6. .7
In' not .lte~ltd
and anaehed with thi~ appliution
II shill! nOl be' procnscd Ind shall be returned
Original PM&DC Registration Certificate for replacement Only if not submitted earlier, a copy of MB8S/8DS degree/dully attested, (For attestation see overleaf instruct.ons) Three recent photographs with white background and both ears visible dUly attested. Photocopy of C.N.I.C Required fee (see details overleaf.) For foreign nationals purpose letter req'Jired from the concerned institution
fee deDosited (in Rupees)
Fee for relention of name in medlcaUdental register
A bank draft/pay order of
as.
any Change in certificate
Courier charges
Urgent fee
Late fee
So.
Total fee
Dated -------------
Name of issuing branch ------------------------------------------a'llOlnt •• RqiJ"vtiol'l
Cilsh can be depos:ted
Fill in with block
at the Bank counter in the P\1&DC
.''1io,01 DoClor " ••"1 be' "',itlt'" 0" ,Itt' bod
./Jt of
lui". d"J/I}
office Islamabad.
letters Date of Birth
Name witn Father's Name
.7. Anesled copy of Tral'llng lener or Experience
Mention qualifications already registered with CoHegelUniversily name
Present Mailing Address
Pennanent Address
cef1ificale 3S a proof or training Institute in case of already reorslered
FCPSlMCPS
Qua~f\catlon.
Undertaking: Icndenake to abIde by the Code of EL'lies (Of practice presenbcd b~ the Pakistar, Medieal and Dental (:Ollnell for registered \-1edleaLtOmtal Pllicull0rm and wil1lnfonn the Ikgl~rrar, PM& OC of any change ofaddn:~ will; in Ihirt) dJys I( con~jde::ed nec~~ary, PM&DC may disclose any mfonnaw.m •••. heo ;uked for Ofowin any IOfol"IT'3lionfrom a:ny of my o::dueatiO:lalUUlIf'..lllol15 ar.d llil>era.le PM&DC iUldthe iWiIlNllon for any liablhry (Of thls action, I funher uooeruke thai If.1:1e:Toneous enlf)' 's !ound in theCef!liicale and r am told !l~'the P"-'I&.D<:to smd the certIficate back fOfeOTTectioTVcanell.l1Ion,Ishall do so im:r.edla:ely ~nd ~hall rlQ( take any bendi: onhe error, Abo\'e mi(lrrnatil'ln i~ COTTlXlandnothing hu been concealed and lffound false Ofeontrary to above, I shall be hallIe for necessary aelHln by the C('lunc11which ma)'lead to caneellaticn "fmy registration with PM&.DC. I tak.: full responsibll\t)' 0~3ulhenfielly of documents submincd ~Io"gWilli this ilpphcatlon
Name
_
Date
Signarure Cdl/
E-mail(Essential)
~
Phone --------------------
C;'\IC
:-':0.
(rOr office use only) Recetved Rs. Ke£istr.'llion renewed
AsslstarH
(Rupees
) Vide rceeipi t-,"o. & valid upto
on
Superintendent
:\ssistanIlDepu:y
~dateet
------
JI,D Card is..<;ucdr.'-Jot issued
Reglslrar
Registrar
_
l::<; f:N E RA L i.
ii. iii. iv
v.
vi.
Attestation: Copy of MBRSfHDS degree, Postgraduate Degree/Diploma duly attested by the PrincipaLNice Principal IDeanlProfessor/Associate/Assistant Professor of McdicallDencal College of Pakistan recognized by rM&DC. Medical Superitendent/Commandant of recognized teaching hospital, Commanding Officer (Anny Medical Corps), EDOHIDHO or authorized officer of Pakistan Embassy abroad. (Mandatory requirement if not submitted earlier. (Stamp of the artcstcrmust show his/her name, designation and present working place). If the required documents are not properly attested and attached with this application it shall not be entertained and shall be returned unaclioned. Doctors coming personally and intending to get their Registration Certificate on Urgent basis are advised to deposit their documents before 10:00 a,m. if courier service is required, fee may be paid accordmgly The certificate can be mailed by PM&DC or the applicant doctor can collect the Registration Certificate personally or waugh an authorized person having an authority letter by applicant his identity and must be in possession of the anginal bank receipt and copy of his/her Cl\'IC. For any additional qualification not already registered use PM&DC Form vi or "ii. For foreign nationals purpose letter required from the concerned instilUtion
2- FEE SCHEDULE FOR RETENTION Basic Medical !Dental Qualification MBBS/EDS. Rs. 500/- per annum ii. Basic McdicallDental Qualification MBBSfBDS with additiunal pustgraduate qualifications Rs 700/- per annum iii Relention Fce for Foreign Nationals (for one year) Rs 1000/. IV. Late Fee (Will he charged if renewed after Il lapse of the six months grace period after the expiry date of Registration Certifieate).Plus Rs. SOO/-per year for the continuing years. Rs. 1000.1. For any change in registration certificate Rs. 2000.1. v. vi. For exteruion of provisional registration. R.5. 1500/vii. URGE1'o'T fEE (for processing on prioriry within three working days) Rs. 1000/viii. COURIER FEE (with in Pakistan) Rs. 150/(out side Pakistan) _ Rs. 1500/- (subject to change in rales) ox. Fee for v~rificatlon / attestation of registranon Rs 1000'. Late fee Rs. 1000/-
,.
For~ign \'ntioni1ls 8.: Pakistani Doctors directly vide mAN
Pakistani
#
arr1ying
li'olll foreign cOLlnlri~s call
ptl)'
fee online
to PM&DC Account
PK43 UNIL 0109 0002 0003 1378 United I30nk Limited (UI31.). The Ice should be in only
Rupees and send the reference numb ....!' of tile lC~ dcpm:itcd online to PM&DC \',1ith :-'ourdocumelllS.
3-1:"1 CASE OF LOSSJ!\HSPLACE:\lENT_OF ~EGISTRATIQS VALIn CERTIFICATE rleas~ use PM&DC (for expircd certificate only bank dratl Rs. 2nOOJ- as duplicare fee & an affidavit on Rs. 20/- stamp paper.)(Speciman
form viii ~ven below)
4- If change of name after marriage is required, please send attested photocopy of Nikanh Nama OR Alfidavil (specimen given below) along with a fee of RS.2000J-. 5- Any false mfonnatlon
given herein shall make the applicant liable for cancellation of P:-.1DC registration
SPEcnlEN
OF AFFIDAVIT ON STAMP PAPER OF RS.201-
FOR FOR LOSS OF REGISTRATION Dr.
SonID/of
--------
declare
CERTIFICATE.
Present Address
___ Permanent
Addrcss
_
lb Oath as under.
I) That I was registered
by the Pakistan
Medical & DenIal Council at Registration
2) That have I tride may best to trace out my registration 3) The certificate bc misused
will be returned
:"la.
dated the
_
but the same could not be traced up till now_
Pakistan Medical &: Dental Council
Islamabad,
If at any time future and will not
with my concurrence.
~) The above statement
Signature
10 Registrar,
certilicate
is correct to the best of my knowledge
and nothing has concealed
or suppressed
by me in this behalf Deponent
and Seal of the court
SPECIMEN OF AFFIDAVIT ON STAMP PAPER OF RS.201FOR TilE CIIANGE NAME AFTER MARRIAGE AFFIDAVIT I Dr.
D/O of
Do hereby solemnly Council
alfmn
as Dr.
(Documenlary
Now II am married to proof attached
i.e Nikah Nama/Govt.
name a.<;gIven above. The above statement suppressed
Presenl Address
and declare on oath that before my marriage notification)
. _ and
Permanent I was registered
r have
Therefore
adopted
Addrcss
with thc Pakistan my married
& Dental
bane as Dr.
I may be issued regisrration
is correct to the best of my knowledge
_ Medical
and belief and nothing
ceniticate
~ in my mamed
has been conccaled
by name in this behalf. Signarurc
and Seal of the court
Deponent
or
