Application for
Other 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.:
MMC20230062925
Application Date :
06/10/2023
Appointment Date :
Appointment time :
Prefix
Sur Name
First Name
Middle Name
Name of Applicant
:
Mr.
GHUMALIYA
MEET
RAMESHBHAI
In Case of Married Women
Maiden Name
:
Permanent Registration
:
BHAKTINAGAR SOCIETY , VAVDI ROAD, MORBI
City/Taluka
:
MORBI
District
:
RAJKOT
State
:
GUJARAT
Pincode
:
363641
Mobile No
:
07359901343
Email Id
:
ghumaliyameet1343@gmail.com
Residential No
:
07359901343
Clinic No
:
Resedential Address in Maharashtra
:
ROOM 1403, THE SOLITAIRE, OPPOSITE MAHIM STATION, SENAPATI BAPAT MARG, MAHIM WEST, MUMBAI
Registration Number
:
G-72450
Registration Date
:
22/02/2021
Registration valid upto date
:
Purpose Of Registration in Maharashtra
:
Higher Education
Noc Letter No
:
Noc Letter Date
:
Authority Council Name
:
GUJRAT MEDICAL COUNCIL
State
:
GUJARAT
Date of birth
:
05/10/1997
:
Gender
:
MALE
Marrital Status
:
SINGLE
Name of the qualifying Examination
:
M.B.B.S.
Name of the educational Institution
:
GMC,RAJKOT
Name of the Statutory University
:
SAURASHTRA UNIVERSITY, GUJARAT
Year of passing the qualifying examination
:
2021
Date of starting Internship
:
10/02/2020
Date of Completion in Internship
:
09/02/2021
Mode of Delivery:
:
Speed Post
I have enclosed following certificates in original alongwith their photocopies :
1.
Two Latest Passport size Photograph
2.
Specimen Copy Signature
3.
Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one)
4.
M.B.B.S. passing/Degree Certificate issued by the university in original
5.
Certificate satisfactory completion of internship(Issued by the Head of the Institution Annexure I & II in original )
6.
Certificate satisfactory completion of internship isuued by University in original
7.
N.O.C. in original from other state Council.
8.
Certificate of Registration issued by state medical council
9.
Self attested photocopy of Aadhar Card
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 Was have been registered under the .............................................................. in the year .... and my registration number is/was ................
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 :
GHUMALIYA MEET RAMESHBHAI
Telephone Numbe:
07359901343
Mobile No :
07359901343
Permanent Address :
BHAKTINAGAR SOCIETY , VAVDI ROAD, MORBI
Pin:
363641
Address in Maharashtra (For other state candidate) :
ROOM 1403, THE SOLITAIRE, OPPOSITE MAHIM STATION, SENAPATI BAPAT MARG, MAHIM WEST, MUMBAI
Place :
MORBI
Name & Signature of Applicant
Date :
06/10/2023
______________________________
FOR OFFICE USE ONLY
______________________________
CHECKLIST for submission of documents
1.
Two Latest Passport size Photograph
Yes
No
2.
Specimen Copy Signature
Yes
No
3.
Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one)
Yes
No
4.
M.B.B.S. passing/Degree Certificate issued by the university in original
Yes
No
5.
Certificate satisfactory completion of internship(Issued by the Head of the Institution Annexure I & II in original )
Yes
No
6.
Certificate satisfactory completion of internship isuued by University in original
Yes
No
7.
N.O.C. in original from other state Council.
Yes
No
8.
Purpose of Registration in Maharashtra : Higher Education (Selection letter or Bonafide Certificate from concerned Institution ) / Service (Appointment Order or In-service Certificate.) / Private Practice (Place of Practice with documentary proof) any one
Yes
No
9.
Residential Proof in Maharashtra (copy of leave and license agreement or Allotment Letter from Government accommodation / Dean/warden/superintendent of Medical college or Hospital /Ration Card/ Domicile Certificate/Electric Bill/ Telephone Bill). any one
Yes
No
10.
Certificate of Registration issued by state medical council
Yes
No
11.
Self attested photocopy of Aadhar Card
Yes
No
Provisional Verification
Final Verification
Name
Name
Signature
Signature
Date
Date