Application for  Maharashtra State  Registration with the
Maharashtra Medical Council, Mumbai
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 2nd Floor,
Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sir,
I request you to register my name under the Maharashtra Medical Council Act., 1965 and further to issue certificate of registration to me. My particulars are as follows :
Application No.: MMC202222130  Application Date : 20/01/2022  
Appointment Date : Appointment time :
  Prefix Sur Name First Name Middle Name
Name of Applicant : Ms. PANDHARPURKAR MAITREYI VIKAS
In Case of Married Women
Maiden Name :
Present Address For Communication : 3B A2, FLAT 6, NEW AJANTA COOP HOUSING SOCIETY, OFF PAUD ROAD, KOTHRUD, DIST- PUNE .
City/Taluka : HAVELI District : PUNE
State : MAHARASHTRA Pincode : 411038
Mobile No : 9767514178 Email Id : maitreyipan22@gmail.com
Residential No : 02025435454 Clinic No :
Date of birth : 29/12/1996   :  
Gender : FEMALE Marrital Status : SINGLE
Name of the qualifying Examination : M.B.B.S. Name of the educational Institution : B.K.L. WALAWALKAR RURAL MEDICAL COLLEGE, RATNAGIRI
Name of the Statutory University : MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK Year of passing the qualifying examination : 2021
Date of starting Internship : 28/02/2020 Date of Completion in Internship : 06/03/2021
Mode of Delivery: : Speed Post
I have enclosed following certificates in original alongwith their photocopies :
1.Certificate satisfactory completion of internship(Issued by the Head of the Institution Annexure I & II in original )
2.Those who have applied after 3 months completion of internship certificate issued by the university . he/she has to submit an affidavit with photograph of Rs.100/- stamp paper mentioning the reason of delay with proof.

DECLARATION

I have carefully read the instructions. I certify that the particulars furnished above are true to the best of my knowledge and belief. I understand that Medical practice without a valid license is not official and lawful. I undertake to inform any change in my postal address due to change in my ordinary place of clinical practice. I read code of medical & Ethics Regulation of Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation 2002). I undertake to abide by these codes in their letter and spirit.
I am applying for registration for the first time and I was not registered as a medical practitioner under any law in India before this.
I am/was provisionally registered under Section 25 of the Indian Medical Council Act,1956 and enclose the certificate of Provisional registration in Original for cancellation.
Note :- The applicants should remember that their names entered in the application must exactly correspond with their names at the university or other Examination, as the case may be
Date:
Place (Signature of the Applicant & Name)

MAHARASHTRA MEDICAL COUNCIL
189/A, Anand Complex, 2nd Floor, Sane Guruji Marg, Arthur Road Naka, Chinchpokali (W), Mumbai - 400 011. Tel. : 022-2307 2464 / 022-2308 3043 Website : www.maharashtramedicalcouncil.in
APPENDIX - 1
DECLARATION
(As per Indian Medical Council {Professional Conduct, Etiquette and Ethics} Regulations 2002)
             At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same.
1.  I solemnly pledge myself to consecrate my life to service of humanity
2.  2.  .Even under threat, I will not use my medical knowledge contrary to the laws of humanity.
3.   I will maintain the ulmost respect for human life from the time of conception.
4. I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
5. I will practice my profession with conscience and dignity
6. The health of my patient will be my first consideration.
7.  I will respect the secrets, which are confined in me.
8. I will give to my teachers the respect and gratitude which is their due.
9.  I will maintain by all means in my power, the honour and noble traditions of medical profession.
10. I will treat my colleagues with all respect and dignity
11. I shall abide by the Code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
I make these promises solemnly, freely and upon my honour
  I read the above declaration and agree to abide by the same.
Full Name : PANDHARPURKAR MAITREYI VIKAS
Telephone Numbe:  02025435454               Mobile No : 9767514178
Permanent Address : 3B A2, FLAT 6, NEW AJANTA COOP HOUSING SOCIETY, OFF PAUD ROAD, KOTHRUD, DIST- PUNE .
Pin: 411038
 
Place : HAVELI Name & Signature of Applicant
Date : 20/01/2022
 






NOTE:- You do not need to submit the print out of original submitted Permanent Registration Application form to MMC office.