FATIMA MEMORIAL HOSPITAL, SHADMAN, LAHORE
A member of Fatima Memorial System
Fatima Memorial Hospital, FMH College of Medicine and Dentistry, Saida Waheed FMH College of Nursing,
FMH College of Postgraduate Medicine, FMH Institute of Allied Health Sciences, ABNI-Community Outreach Program
UAN: +92 42 111 555 600, Fax: +92 42 7570586, Website: www.fatimamemorial.org.pk, E-mail: hrd@fmsystem.org
APPLICATION FORM FOR HOUSE JOB / INTERNSHIP
1. Please complete all sections and attach any additional information if necessary or you wish to provide
2. Your application and personal information will be kept confidential
Section: I (Personal Information)
Name: ______________________________________________________________________________
Please Paste 2
Father’s / Husband’s Name: ____________________________________________________________ Passport Size
Photograph
Gender: Male Female Marital Status: Single Married Blood Group ___________
Date of Birth: - - Place of Birth: _____________________________
CNIC #: - - Religion: ______________Nationality: _____________
Permanent Address: __________________________________________________________________________________
Telephone: ______________________ Mobile Phone: ____________________ E-Mail: _________________________
Present Address: _____________________________________________________________________________________
Telephone: _______________________ Mobile Phone: _____________________ E-Mail: ________________________
In case of emergency person to be contacted:
Name: __________________________________________________ Relationship: ___________________________
Mailing Address: _____________________________________________________________________________________
Telephone: ___________________________________ Mobile Phone: _____________________________________
Fax No. ______________________________________ E-Mail: ___________________________________________
Section: II (Registration with Pakistan Medical & Dental Council)
PMDC Registration No: ________________________ Date: __________________ Valid Up To: ___________________
Section: III (Academic Record)
MBBS / BDS Passing Year: _______________ Session: ______________ Annual Supplementary
Aggregate Total
Professionals Attempt Roll No. Percentage College / University
Marks Marks
1st Prof Part-I
1st Prof Part-II
2nd Prof
3rd Prof
Final Prof
HR05 01/150918
Section: IV (Professional Record)
Please give detail of Internship / House Job (if any) in chronological order, starting with most recent:
Sr. Duration
Specialty Position Held Organization / Hospital
# From To
1.
2.
3.
4.
Section: V (References)
Is any employee of FMH is related to you? Yes No
(If yes please give below detail):
Name: __________________________________________ Designation: ___________________________________
Department: _____________________________________ Relationship with you: ___________________________
Other References:
Sr. Business /
Full Name Full Address Contact
# Occupation
Office
1. Mobile
E-Mail
Office
2. Mobile
E-Mail
Section: VI (Declaration / Undertaking)
I hereby declare that the statements made by me in this form are true and correct to the best of my knowledge. I understand
that I will be held liable for any material misrepresentation, omission made thereon or any other document requested by or
submitted to the Organization. I agree to hold Fatima Memorial System harmless for the use of the data in this form by third
parties for purpose and other those for which they wore provide. I also undertake that I will abide by the rules & regulations
of the Fatima Memorial System
Applicant Signature: _______________________ Date: ____________________
Enclosures:
i. Copy of CNIC
ii. Two recent passport size photographs
iii. Copy of Character Certificate from the Medical College
iv. Copy of PMC Registration Certificate
v. Copy of Attempt Certificate
vi. Copies of all Professionals & Degree of MBBS/BDS
vii. Copies of Matric & FSC Degree
viii. Copies of Experience certificates (In case of Internship / House Job)
ix. Copy of Domicile Certificate
HR05 01/150918
