SHAHEED ZULFIQAR ALI BHUTTO
MEDICAL UNIVERSITY
Roll No____________
(Office Use Only)
EXAMINATIONS FORM FOR MBBS PROGRAM
N OTE:
The form shall be submitted to the Office of the Controller of Examinations.
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 spelling/ Please affix
name will be finally printed on the Degree issued to you by the University . photograph here
Please fill in the form in black ink and clearly print or type only in CAPITAL letters and avoid attested from front
contact with the edges of the boxes. A box may be left empty wherever a word ends and a new side ( 3X3 cm )
word begins in the same line or where nothing further is to be written. with blue background
Avoid any over- writing and other mistakes while filling in the form. Please make sure the form is
filled in as neatly as possible.
Examination form shall be filled in legibly and correctly by the candidate in his/ her own
handwriting. Incomplete and incorrect examination form 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 ticked or checked.
or
Examination f o r m for: MBBS IN - - - - - - - - - -
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First Professional Part _____ Second Professional
Third Professional Final Professional
APPLICANT’S PERSONAL INFORMATION
Full Name (first, middle, last)
2
Father’s Name (first, middle, last)
3
Applicant’s NIC (provide copy)
4 _
Name of Institution
5
Registration Number Nationality
6 ____________________________________________
7
Previous Examination (annual/ supplementary- year) Previous Examination Roll No
8 9
Subjects(s in which to appear:
10 1. ……………………………………………………… 6. …………………………………………………
2. ……………………………………………………… 7. …………………………………………………
3. ……………………………………………………… 8. …………………………………………………
4. ……………………………………………………… 9. …………………………………………………
5. ……………………………………………………… 10. …………………………………………………
11 Mailing Address (mention all relevant inform at ion like post code etc.)
-- - -- -- -- -- -- -- -- - - --- -- - - -- -- -- - -- - -- -- -- -- -- -- - -- -- -- -- -- --- -- -- --- - -- - - --- -- - - -- -- -- - -- -- -- - - -- -- -- - - -- -- -- --- -- -- -- -- -- -- - -- - - -
-- - -- -- -- -- -- -- -- - -- -- -- - - -- -- -- - -- - -- -- -- -- -- -- - -- -- -- -- -- --- -- -- --- - -- - - --- -- - - -- -- -- - -- -- -- - - -- -- -- - - -- -- -- --- -- -- -- -- -- -- - -- - - --
Mobile/ Telephone Number (with city code) E-mail / Fax #
12
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SHAHEED ZULFIQAR ALI BHUTTO
MEDICAL UNIVERSITY
Appeared in the __________ Professional BDS __________ Annual / Supplementary Examination 20___, held
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in________________ under Roll No. ___________ and failed in the subject( s) of:
1. ……………………………………………………… 6. …………………………………………………
2. ……………………………………………………… 7. …………………………………………………
3. ……………………………………………………… 8. …………………………………………………
4. ……………………………………………………… 9. …………………………………………………
5. ……………………………………………………… 10. …………………………………………………
14 Fee Paid Rs. Mode of Payment Draft Bank Receipt
Draft/ Bank Receipt No: _ Date:
(DD / MM / YYYY)
NOTE: Attach original Bank Draft/ Bank Receipt with this form
Documents to be attached:
15 I have attached attested copies of the following documents with this form ( tick appropriate box)
Certificate of F. Sc
DMC of MBBS of previous Professional
03 photographs size (3x3 cm) attested from front side paste at given place and
01 photograph size (3x3 cm) (attested from back side) attach with Examination Form.
CERTIFICATE BY T H E APPLICANT
I hereby solemnly declare 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 examination without
being eligible for it is a crime punishable under the act of law, and in such case, the university has
every right to cancel my result.
Date: _____________________ _________________________
Signature e of the applicant
15 CERTIFICATE BY THE PRINCIPAL
A certificate on a pattern provided below will be sent to the Examination Department not later than two
weeks prior to the commencement of the examination. Otherwise Roll # slip / Admittance card shall not be issued
to their candidates.
{I certify that the candidate is eligible in all respects as per Rules & Regulation of University to appear
in this examination.
Dated: _ _ _ _ _ __ }
Signature of Principal (with stamp)
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SHAHEED ZULFIQAR ALI BHUTTO
MEDICAL UNIVERSITY
ROLL NO SLIP Roll No:
(Office use only)
(FOR SUPERINTENDENT)
Examination:
Name: Please Paste
photograph here
Father’s Name:
attested from front
Name of Institution: side ( 3X3 cm )
with blue background
Subjects in which to be examined:
Controller of Examinations
Note: Cell/Mobile Phones, Palm Tops, Mini computers and any other electronic equipment likely to help the
candidates are completely prohibited in the Examination centers. Moreover Cell/Mobile Phones shall not be
collected by the center superintendent or University administration at examination center.
_______________________
Signature of the Candidate
…………………………………………………………………………………………………………………………………………………………………..
SHAHEED ZULFIQAR ALI BHUTTO MEDICAL UNIVERSITY
ISLAMABAD
Roll No:
ROLL NO SLIP (Office use only)
(FOR CANDIDATE, TO BE HANDED OVER TO THE SUPERINTENDENT)
Examination:
Name:
Please Paste
Father’s Name:
photograph here
Name of Institution: attested from front
side ( 3X3 cm )
Subjects in which to be examined: with blue background
Controller of Examinations
Note: Cell/Mobile Phones, Palm Tops, Mini computers and any other electronic equipment likely to help the
candidates are completely prohibited in the Examination centers. Moreover Cell/Mobile Phones shall not be
collected by the center superintendent or University administration at examination center.
_______________________
Signature of the Candidate
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