Application for
with the
Maharashtra Medical Council, Mumbai
Application No :
Date :
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 2nd Floor,
Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sub: Dr (Smt/Shri)
Registration No:
Registration Date :
Valid upto Date :
Sir,
I the undersigned applicant, request yoy that my name may be continued on the Register of Medical Practitioners maintained by the Maharashtra Medical Council as per 23 (a)/23 (c) of MMC Act 1965 and amendment 2003. My particulars are as Follows :
Name of Applicant
:
Name of Father
:
Name of Mother
:
In Case of Married Women
Maiden Name
:
RESEDENTIAL ADDRESS
:
City
:
District
:
State
:
Country
:
Pincode
:
PRESENT PLACE OF WORKING
:
Name Of working Country
:
Name of General Medical Council/ Licensing authority
:
Registration No of Current Country
:
General Medical Council/ Licensing authority Registration Date
:
Valid upto date of registration of Current country
:
Email id of General Medical Council/Licensing Authority
:
Date of birth
:
Tel No (Res)
:
Clinic No
:
Mobile No
:
Email Id
:
Total Obtained Credits Points
:
Remaining Credits Points
:
Is Exemption
:
Exemption from earning credit points Category
:
Qualification Details
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
Receipt Date
:
I have uploaded following documents:
DECLARATION (Registered Medical Practitioner)
I shall abide by the Code of medical Ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
Date :
Applicant signature
______________________________
FOR OFFICE USE ONLY
______________________________
CHECKLIST for submission of documents
Provisional Verification
Final Verification
Name
Name
Signature
Signature
Date
Date