BANGLADESH COLLEGE OF PHYSICIANS AND SURGEONS (BCPS)

Application Form

(Training allowances for the FCPS Part-II honorary trainees)


General Information

Applicant’s Name (Block Letters):

Father’s/Spouse Name (Block Letters):

Mother’s Name (Block Letters):

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:

  *(Only Number)
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
Current training database (Please mention here current six month training duration only, if you have)

Are you continuing the FCPS training? :

Yes No
Have you obtained FCPS training before (Please mention here previous completed training of every six month duration)
Name of the Institutes Name of the Department Name of the Supervisor Designation Duration of training
Starting date Ending date

Mention the name of the institutes with department recognized by BCPS according to your choice where you want to obtain the fellowship training: (Please schedule the rest of training Including FCPS course and excluding current duration)

Name of the Institutes Name of the Department Duration of training
Starting date Ending date
Applicant's Personal Bank Information:

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 with Date:

  (Resolution: 300x80 pixels, Size: below 300 kb, signature)

1. Recent passport size color photograph :

  (Resolution: 300x300 pixels, Size: below 300 kb, picture)

2. Congratulation letter of FCPS Part-I/ FCPS Part-I passed document:

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. Joining letter/ Testimonial:

9. Other necessary documents: