Admission Form No.

MBBS-1/2016-17_________

APPLICATION REQUEST FORM

CMH INSTITUTE OF MEDICAL SCIENCES BAHAWALPUR
Central Library Road, Near DHA Office Bahawalpur Cantonment
2 Latest
Passport Size
Photographs
(Blue
background)
4x4 cm

Status of Applicant (Please tick one)

I wish to apply as: Pakistani Student Foreign/Overseas Pakistani Wards of Army Personnel
(If you qualify and want to apply in two categories please indicate your priority as 1st and 2nd)
1. Full Name of candidate:
(in Block letters)
2. Gender: Male Female
3. Date of Birth: (DD-MM-YYY)______________________ 4. Place of Birth:_______________
5. Nationality (According to Passport)________________ 6. Religion: _______________
7. CNIC No: (if residing abroad, provide Social Security No)

8. Passport No:

9. Current Residential Address:_______________________________________________________

_______________________________________________________
10. Permanent Address (if different from above):__________________________________________
__________________________________________
11. Applicants Mobile No:________________________ 12. E-mail_______________________
13. Fathers/Guardians Particular:
a. Name ________________________ b. CNIC No._____________________________
c. Occupation____________________ d. Monthly Income_______________________
e. E-mail Address:_________________
f. Phone: Office: _____________ Residence______________ Mobile No_________________

14. Mothers Particulars:

a. Name________________________ b. CNIC No._______________________________
c. Occupation____________________ d. Monthly Income_________________________
e. e-mail Address_________________ f. Phone_________________________________
15. Whom to contact in case of Emergency?
a. Name_____________ b. Relation ____________________________________________

c. Phone-1 ___________ d. Phone-2 ___________________ e. Mobile No__________

f. Postal Address ______________________________________________

16 Have you ever been admitted to any Medical College previously? Yes No
17. Academic Record:
Examination Subject Year of Roll No Institution /Board Marks Obtained
Passing /Total Marks
Matriculation/O Levels
FSc /A-Levels
Other qualifications ( if any)
(Candidates who hold qualifications other than FSc and Matriculation will be required to provide Equivalence
Certificate from the Inter Board Committee Chairman / IBCC)
18. Entry Test Score (whichever applicable):
Examination Year of Passing Marks Obtained Total Marks
NUMS Entry Test
UHS Entry Test
Provincial MCAT
SAT II

19. Do you have any medical illness? Yes No

20. Are you on any kind of medication? Yes No
21. Hostel accommodation required? Yes No

22. Declaration: I Mr. /Ms. __________________________Son/Daughter of ___________________an applicant

for admission to CMH Institute of Medical Sciences Bahawalpur (CIMS Bahawalpur) solemnly affirm and declare
that the above information provided by me is correct. I have obtained and understood the rules / terms and
conditions of the admission procedure. I agree to abide by the rules and regulations of CIMS Bahawalpur
currently stated as well as any modification of these rules and regulations from time to time by authorities of
the institution. I undertake that I have adequate financial resources to support my studies at the CIMS
Bahawalpur for the entire duration of the course of study. I hereby assure that all dues will be paid by the due
date according to payment schedule of CIMS Bahawalpur.

Applicants Signature:__________ Parents/Guardians Signature:__________ Date:______

23. Steps in submission of application:-
a. Complete application in all respects
b. Deposit processing fee Rs. 6000/- or Rs. 12,000/- (or US$ 120) (as applicable) in the form of
bank draft/pay order or online deposit in bank as per para 25 below and get bank
receipt/challan copy.
c. Scanned copies of application and bank draft/pay order or online bank receipt /challan be sent
through e-mail at admissions@cimsbwp.com.pk at CIMS Bahawalpur.
d. Submit completed application with bank draft/pay order (original) or on line bank deposit slip
(copy) preferably in person or via courier to Admission office, CIMS Bahawalpur, Central
Library road, Near DHA Office, Bahawalpur Cantt by due date.
24. Attach (photocopies) of following documents with the application form:-
CNIC (father). CNIC of Student or Form B. (in case less than 18 years)
Matric/O Levels FSc/A Levels/ Equivalent certificate
NUMS/UHS/provincial MCAT/SAT-II entry test result. Domicile Certificate.
Migration Certificate in original if student migrating from another board (out of Punjab).
Bank Deposit/Challan/ Draft Passport (Foreign students Only)
25. Details of Bank deposit (for processing fee):
Name of Bank_____________________ Branch _____________________________
Account No_______________________ Amount deposited Rs.__________(in words__________
Date ____________________ Bank Stamp