* = Required fields, - Bangla Characters are not accpeted
Name:* (Block Letters)
Email Address:*
Mobile Number:*
Date:
Service:
Degree: (Select "Others" for Data Analysis, Abstract, Publications) Please select a category FCPS MD/MS MD/MS student OLD curriculum (DU) MD/MS student OLD curriculum (BSMMU) MPH MPhil PhD Others
Package: If Need To Change Package Click Here
Payment Clearance with Price in BDT: (ex: Select partial if payment in 2 installments) Complete (15000BDT) Partial (7500BDT)
Payment Method:* BKash Rocket Nogod M Cash AB Cash T Cash ONE Bank Wallet Sure Cash D Money VISA Card Master Card Internet Banking
Present Address:* (where any courier can reach)
Entry of Phase B: (If applicable)
Date of Passing FCPS Part-1:
Subject of your Post-graduation:*
Study Period: Extend of your study period (Example: January 2018 to December 2018)
Name of the Study Title (Block letter):*
Date of Title Passing/ Date if Protocol Acceptance (if applicable):*
Name, Degree and Designation of your Guide:*
Name, Degree and Designation of your Co-guide: (if Not Available please write - NA)
Place of Study:* (Example: Department of Hematology), you can add more than one department here
Sample Size (Applicable for Dissertation/Thesis):* (if not known please write - 0)
Reference Style:* Vancouver Vancouver BCPS Harvard BSMMU 2008 Harvard BSMMU new Harvard cite them 10 th edition Harvard Anglia Ruskin university Harvard Mozammel sir book style APA style Schicago manual Others
Social Network ID (Viber/Whats App):* It will be used in Correction Phase
Any Necessary Comments:
