Application for Renewal Of Registration with the
Maharashtra Medical Council, Mumbai

Application No : MMC20230002910	Date : 18/01/2023
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) SHIJI K. S.
Registration No: 2012072090 Registration Date : 11/07/2012 Valid upto Date :11/07/2027
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	:	Ms.	SHIJI	K.	S.
Name of Father	:	Mr.	SUBHASHDAS	K.	G.
Name of Mother	:	Mrs.	SUBHASH	SHOBHA
In Case of Married Women
Maiden Name	:	-

RESEDENTIAL ADDRESS	:	FLAT NO-D1-202, KUNAL ICON, PIMPLE SOUDAGAR, AUNDH CAMP, PUNE
City	:	PUNE	District	:	PUNE
State	:	MAHARASHTRA	Country	:	INDIA
Pincode	:	411027

Date of birth	:	19/05/1981	Tel No (Res)	:		Clinic No	:
Mobile No	:	9823237138	Email Id	:	dr_shiji@yahoo.co.in

Total Obtained Credits Points	:	26
Remaining Credits Points	:	4

Qualification Details

	Details of Qualification	Name of College	University	Passing Year	Certificate No	Certificate Date
1.	M.B.B.S.	GOVERNMENT MEDICAL COLLEGE, THRISSUR	UNIVERSITY OF CALICUT, KERALA	2005
2.	M.D.(Paediatrics)	BJMC PUNE	MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK	2010	2887/2013	22/10/2013

Pariticulars Of Payment
Payment Mode	:	Online Payment
Receipt No	:	202301873024695
Receipt Date	:	19/01/2023

I have uploaded following documents:

1.	Latest Passport size Photograph
2.	Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
3.	Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
4.	Original Undertaking

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 : 18/01/2023

Applicant signature

NOTE:- You need to submit the print out of original submitted Renewal Application form With original Affidavit & Indemntity Bond to MMC office.

______________________________ FOR OFFICE USE ONLY ______________________________

CHECKLIST for submission of documents

1.	Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)	Yes	No
2.	Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)	Yes	No


Provisional Verification	Final Verification
Name	Name
Signature	Signature
Date	Date