FATIMA MEMORIAL SYSTEM, SHADMAN, LAHORE

NUR STUDENT LEADERSHIP PROGRAM (NSLP)

Instructions

1. NSLP is open for all students of O Levels, A-Levels/Intermediate and above, It is not restricted to pre-medical students

2. Please complete all sections and attach any additional information, if required

3. Your application and personal information will be kept confidential

4. Use black / blue ink only for filling the form

5. Incomplete form will not be accepted

Section: I (Personal Information) (Please Write in Capital letters)

Name: __________________________________________________________________________

Father’s / Mother’s Name: _________________________________________________________

Father’s / Mother’s Occupation_____________________________________________________

Gender: Male Female Nationality: _________________________

Date of Birth: DD / MM / Year

Permanent Address: __________________________________________________________________________________

Land Line No.: _______________________________ Mobile Phone: __________________________________________

Present Address: _____________________________________________________________________________________

Contact: __________________________________________E-Mail: ___________________________________________

In case of emergency person to be contacted:

Name: _________________________Relationship: _________________Contact#_____________________________________

Mailing Address:

_________________________________________________________________________________________________________

Section: II (Academic record / achievements)

Current Class: ______________________________Current School/College/University__________________________________________

Qualification Name of Institution Year Marks

Obtained

Total

Marks

Grade /

Division Major Subject

- -

APPLICATION FORM

Passport Size

Photograph

2 photos

If you have any academic / nonacademic achievements, awards or honors, please provide details below:

Sr.

#: Award / Achievement / Honor Subject / Field Year Class Institution

1.

2.

3.

Section: III (Please mark your desired profession):

If you intend to pursue a medical profession, please specify your preference:

MBBS BDS Allied Health Sciences

Section: IV (previous internship detail)

Have you attended internship at Fatima Memorial System? Yes No

If you have attended internship at any other institution, please provide details below

Sr.

# Organization / Institution Year Session

Duration Specialty

From To

1.

2.

3.

Section: V (References)

How did you find out about internship at FMH?

Through your Institution Through a friend Through our website

Any Other__________________________________________________________________________________

Section: VI (Your Talents)

At the end of Internship we arrange a closing ceremony, please specify your talents which we can utilize at that occasion:

Musical Instrument (specify) ___________________ Organizing

Drama / Acting Stage Decoration

Photography Script Writing

Video Capturing Make Up

Comparing Art Work / Painting

Singing Any Other__________________

Section: VII (The Schedule)

INTERNSHIP SLOTS

Please write your module’s name: __________________________________________________

Modules Structure

Duration 2 Weeks 3 Weeks (Mentors) 4 Weeks

Program: T2 (Tier 2) T3 (Tier 3) Departmental

Academic

Baseline

O & A Level/Equivalent O & A Level /

Equivalent

Bachelors/ Masters

Dates

available

2.1: 20th June – 1st July, 2016

2.2: 11th July – 22nd July, 2016

2.3: 25th July - 5th August, 2016

(BLS will be offered optionally

with a separate cost of Rs.1500)

3.1: 20th June – 8th

July 2016

3.2: 11th July 2016 –

29th July 2016

(BLS will be offered

optionally with a

separate cost of

Rs.1500)

4.1: 20th June -15th July, 2016

(one week break for Eid-ul-

Fitr)

4.2: 18th July -12th August,

2016

Registration

Fee: PKRs. 3500 PKRs. 5000 PKRs. 4000

Other programs:

Program: Research Apprentice

Program (RAP)

Community Outreach

Module (Girls only)

Academic

Baseline Bachelors/ Masters Bachelors/ Masters

Dates

available

R1: 20th June – 1st July, 2016

R2: 11th July – 22nd July, 2016

R3: 25th July - 5th August, 2016

C1: 20th June -15th July, 2016

(one week break for Eid-ul-

Fitr)

C2: 18th July -12th August, 2016

Registration

Fee: PKRs. 5000 PKRs. 5000

Please select one from the following for 100 hours (Bachelor and Master Degree) 4/6 weeks:

Community Work Food & Nutrition Services Psychiatry

Human Resource Microbiology

Signature of Parents: _________________________ Date: ____________________

Signature of Principal: _______________________ Date: ____________________

Or Administrator (if applicable)

Section: VIII (Declaration)

I hereby declare that the statements made by me in this form are true

and correct to the best of my knowledge. I understand that I will be

held liable for any material misrepresentation, omission made

thereon or any other document requested by or submitted to the

Organization. I also undertake that I will abide by the rules &

regulations of the Fatima Memorial System and will not participate

in any unlawful activities at FMS.

Applicant’s Signature: ________________________________

Date: _______________________

Please submit this form latest by June 1st 2016 to: Nur Student Leadership Program

Internship Office Room # 25, 4th Floor, College Building Fatima Memorial Hospital, Shadman, Lahore-54000

Cell : +92 332 1045601 Land line : (042) 111-555-600 Ext : 353

Email : nslp@nurfoundation.org

1. Please note while we will try to accommodate you as per your preference, we cannot guarantee availability of seats in the preferred time slots

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