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Application Form For Admission - 1671521644

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Kamlesh Ladhani
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25 views2 pages

Application Form For Admission - 1671521644

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Uploaded by

Kamlesh Ladhani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FOR ADMISSION

Certified Healthcare Quality Professional


Certified Healthcare Project Management Professional

A. PERSONAL DATA
1.NAME:FATHER’S NAME: Mr. Ms.

2.COMPANY:
3.ADDRESS(Office):
(Residence):
4.DATE OF BIRTH(Day/Month/Year): 5.CNIC.NUMBER:
6.CELL: 7.WORKPHONE:
8.FAX: 9. E-MAIL:

B. EDUCATION (Attach your credentials with the application)


14.GRADE /
12.DATESATTENDED 13.NO.OFACADEMIC YEARS
11.COLLEGE OR UNIVERISTY DIVISION
10.DEGREE
(Name City/Country) FROM TO
(Year) (Year)

C. SUMMARY OF PROFESSIONAL EXPERIENCE


17.START DATE 18.FINISH DATE
15.POSITION 16.EMPLOYER 19.YEARS IN POSITION
(Month/Year) (Month/Year)

TOTAL YEARS

D. TECHNICAL TRAININGS/ COURSES

23.DATESATTENDED
20.DESCRIPTION OF 21.INSTITUTE 22.DURATION FROM TO
TRAININGS/COURSES (Month/Year) (Month/Year)
E. PROFESSIONAL MEMBERSHIPS
24.TYPE OF ME MEMBERSHIP 25.PROFESSIONAL BODY 26. MEMBER SINCE

F. EMPLOYER’SAPPROVAL (incase the candidate is sponsor by an employer)


1. I certify that the information provided by the candidate is accurate to the best of my knowledge.
2. I have no objection what so ever on the candidate’s admission and participation in the course.

EMPLOYER’S STAMP & SIGNATURE NAME DATE

G.CANDIDATE’S VALIDATION
I certify that the statements above including my attachments are accurate to the best of my knowledge there by authorize the institute to verify any information
submitted.. I understand that any falsification of any information in this application or attachment may cause for rejection or withdrawal of certification.
I further agree to hold the DUHS and PIQC harmless from any additional liability in the event this application is rejected on the basis of information furnished to
DUHS and PIQC by me or third person which would make me ineligible.
I further agree to adhere to the DUHS and PIQC’s Code of Professional Conducted if I am certified, to meet the requirements of continuous certification.

APPLICANT’S SIGNATURE DATE

DOCUMENTSTO BEATTACHED
(Please ensure that the following documents have been attached and tick appropriately)
1. Application Fee:Rs.3,000/-(Non–Refundable)
2. Passport Size Photographs (Three)
3. Professional Degree(s) /Provisional Certificate(s)–Photocopies
4. Certificate(s) of training Courses –Photocopies
5. Bio-data /Resume

PIQC USEONLY
CHECK POINTS
PERSONALINFORMATION COMPANY INFORMATION REFERENCE DOCUMENTS FEESPAID
CHECKED BY: DATE:

(SIGNATURE)
REVIEWANDAPPROVAL THE APPLICATION HAS BEEN REJECTED
REVIEW/APPROVER: DATE:

(SIGNATURE)
Contact for Registration: Dow University of Health Sciences
PIQC Institute of Quality Baba-e-Urdu Road Karachi, Pakistan
C-32 Block 17, Gulshan-e-Iqbal, Karachi, Postal Code:74200
Pakistan
Tel: (92-21) 34979440; 34979449, 03150027826 Phone:+ 92-21 - 99215754-57 & 38771000
03332163620
Email: [email protected]
Web: www.piqc.edu.pk

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