Serial No: 	

UNIVERSITY OF HEALTH SCIENCES Lahore
Khayaban-e-Jamia Punjab, Lahore Phone No (Off) 042-99231304-9

ADMISSION FORM FOR POST GRADUATE CERTIFICATE IN MEDICAL TEACHING

NOTE:

§ 	The name/spelling of the candidate and his/her father name be correctly written on this  form,  exactly  as  per  the  Matric/Equivalence Certificate, because,  the  same

 
Please Paste

spelling  /name  will  be  finally  printed  on  the  Certificate  issued  to  you  by  the
University.
§ 	Pleas e fill in the form with black ink only in CAPITAL letters and avoid contact with the edges of the boxes.
A box may be left empty wherever a word ends and a new word begins in the same line or where nothing further is to be written.
§ 	Avoid any over-writing and other mistakes while filling in the form. Please make sure the form is filled in as neatly as possible.
§ 	Admission form s hall be filled in legibly and correctly by the candidate in his/her own handwriting. Incomplete and incorrect admission for m may be cancelled. The University shall not take any responsibility for the consequences.
§ 	Wherever small choice field boxes “     ” are provided in the form, the box adjacent to the appropriate answer is to be tic ked or crossed. þ Or ý 

photograph here
attested from front side (3X3 cm) with blue
background

1	Admission form  for Post Graduate Certificate in Medical Teaching
At NMC, Multan		At UHS, Lahore

Full Name (first, middle, last)
2

Father’s Name (first, middle, last)
3

Applicant’s NIC
4

Name of Institution

5

6
	Nationality ……………………………………………………………………….

7	Mailing Address (mention all relevant information like post c ode etc.)
…………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………..

Mobile/ Telephone Number (with city c ode)	E-mail:
8

  9	Current Job Status:

      Professor                 Associate Professor                    Assistant Professor                 Lecturer / Demonstrator / Senior Registrar
	Other________________
10	Job Experience:

(The applicant MUST have at least 1 year of teaching experience in a Medical College/ Institution for as a Demonstrator / Senior Demonstrator/Senior Registrar/ Assistant Professor and above.

i) 	------------------------------------------------------------- ii)	------------------------------------------------------------ iii)	------------------------------------------------------------
iv)	------------------------------------------------------------

Documents to be attached
11
I have attached attested copies of the following documents with this form (tick appropriate box) 
	Degree of MBBS/BDS	House Job Certificate	Current Teaching Position
03 photographs size (3×3 cm) paste at given place and

01 photograph size (3×3 cm) (attested from back side) attach with admission Forms.

CERTIFICATE BY THE APPLICANT 

12		I hereby solemnly Edeclare that: (1) the information provided and statement made by me in this form are true and
correct to the best of my knowledge and belief and nothing material has been concealed or withheld herein. (2) I shall be
Responsible if my application form is rejected for any errors, wrong or incomplete entries made by me. (3) I understand that applying for this course without being eligible for it is a crime punishable under the act of law, and in such case, the university has every right toCcancel my application. (4) If selected, I will be responsible to submit the require course fee of Rs. 40,000/- prior to the start of course.

________________________
Date: 	T C

Signature of the applicant

13	CERTIFICATE BY THE PRINCIPAL

1. 	It is certified that Dr.___________________________	__has_____ year of teaching experience as Demonstrator/Senior
Registrar/Assistant Professor/Associate Professor/Professor.
2. 	The above mentioned doctor will be allowed to attend the teaching sessions at University of Health Sciences for the duration of the course that shall not exceed ten working days.

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   Dated: 

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Signature of Principal (with stamp)