BANGLADESH COLLEGE OF PHYSICIANS AND SURGEONS (BCPS)

Application form

(Training allowances for the FCPS Part-I qualified honorary trainees)

Applicant’s Name (Block Letters):

Father’s/Spouse Name:

Mother’s Name:

Date of birth

Nationality:

Religion:

National ID No:

Address of communication:

Mobile:

Tel (Res):

E-mail:

Permanent Address:

MBBS/BDS Data

Year of Qualification:

Institute:

BMDC Reg. No:

FCPS PART-I Examination Data

Specialty:

Roll No:

Year of Passing:

Month:

Online Reg. No./Reg. No. (after passing FCPS Part-I)

Are you selected or continuing the residency training/diploma course/ Govt. service/Private service? :

Yes No

Starting date:

Ending date:

Are you continuing the FCPS training? :

Yes No
If yes, please fill up the following table
Name of the Institutes Name of the Department Name of the Supervisor Designation Duration of training
Starting date Ending date

Have you obtained FCPS training before:
Name of the Institutes Name of the Department Name of the Supervisor Designation Duration of training
Starting date Ending date

Please mentioned the name of the three government institutes with department recognized by BCPS according to your choice where you want to obtain the fellowship training:
Name of the Institutes Name of the Department Duration of training
Starting date Ending date

Bank Information of the applicants:

Name in block letters (as per Bank Account):

Name of the bank:

Name of the branch:

Account Number (13 digits or above):

Routing Number:

Undertaking:

I Dr. ....... declared that the information given by me in this form is entirely true and authentic. The application may be cancelled if any information mentioned above is found to be false or incomplete.

Agree

Enclosures: (The applicants have to scan and upload the following documents)

Applicant’s Signature & Date:

1. Recent passport size color photograph :

2. Congratulation letter of FCPS Part-I:

3. Certificate of MBBS/BDS:

4. Permanent registration certificate of BMDC:

5. Training certificates (if applicable):

6. A page of the Bank Cheque book of the applicant :

7. National ID card:

8. Other necessary documents:

9. Other necessary documents: