Application for
Provisional Registration
with the
Maharashtra Medical Council, Mumbai
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 1st Floor, Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sir,
I Request you to register my name provisionally under section 25 of the Indian Medical Council Act 1956 and issue the necessary certificate. My particulars are as follows:
Application No.:
MMC20230022244
Application Date :
19/04/2023
Appointment Date :
Appointment time :
Prefix
Sur Name
First Name
Middle Name
Name of Applicant
:
Ms.
GUPTA
SALONI
SUSHIL
Name of Father
:
Mr.
GUPTA
SUSHIL
MOTILAL
Name of Mother
:
Mrs.
GUPTA
SUNITA
SUSHIL
In Case of Married Women
Maiden Name
:
Name of Husband
:
Present Address For Communication
:
PLOT NO 46, RING ROAD, SUYOG NAGAR, SAKET NAGAR, NAGPUR
City/Taluka
:
NAGPUR
District
:
NAGPUR
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
440027
Nationality
:
INDIAN
Mobile No
:
7378868287
Email Id
:
salonigupta2024@gmail.com
Residential No
:
Clinic No
:
Date of birth
:
24/05/2000
:
Gender
:
F
Marrital Status
:
S
Name of the qualifying Examination
:
M.B.B.S.
Name of the College
:
JAWAHARLAL NEHRU MEDICAL COLLEGE,SAWANGI (MEGHE),WARDHA
Name of the Univeristy
:
DATTA MEGHE INSTITUTE OF MEDICAL SCIENCES DEEMED UNIVERSITY, WARDHA
Year of passing the qualifying examination
:
2023
Date of starting Internship
:
15/03/2023
Date of Completion in Internship
:
13/03/2024
I have enclosed following certified copies attested by Dean of Medical College from where he has passed.
1.
Passport size Photograph
2.
Latest Signature
3.
Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one)
4.
Marklist for the qualifying examination
5.
Certificate of passing the qualifying examination/Online Markssheet
6.
Internship Letter
7.
Bonafide certificate
DECLARATION (Student)
I am applying for Provisional Registration for the first time and I was not registered as a medical practitioner in India / Abroad before the date of this application. I am aware of the legal consequences of misleading the Maharashtra Medical Council or violating the limitations on practice in herewith provisional registration. I have carefully read the instructions and I certify that the particulars furnished above are true to the best of my knoweledge and belief.
Date:
:
Place
:
(Signature of the Applicant & Name)
Particulars Of Payment
Receipt No
:
202310989797246
Receipt Date
20/04/2023
CERTIFICATION BY DEAN
Certified that the above information of the candidate is verified from the record of the College / Institute and found to be Correct .The said Intern is Bonafide Student of this College and have started his/her Internship from
15/03/2023
Place
:
(Signature of Dean)
Date
:
______________________________
FOR OFFICE USE ONLY
______________________________
CHECKLIST for submission of documents
1.
Passport size Photograph
Yes
No
2.
Latest Signature
Yes
No
3.
Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one)
Yes
No
4.
Marklist for the qualifying examination
Yes
No
5.
Certificate of passing the qualifying examination/Online Markssheet
Yes
No
6.
Internship Letter
Yes
No
7.
Bonafide certificate
Yes
No
Provisional Verification
Final Verification
Name
Name
Signature
Signature
Date
Date