Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC201603023 Date : 09/02/2016
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)  TRIPATHI SUSHILKUMAR PARSHURAM
Registration No:  2006031690   Registration Date : 16/03/2006   Valid upto Date :16/03/2026
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 : Mr. TRIPATHI SUSHILKUMAR PARSHURAM
Name of Father : Mr. TRIPATHI PARSHURAM SHIVMURAT
Name of Mother : Mrs. TRIPATHI FULPATI PARSHURAM
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : C/O. VINOD P. TRIPATHI, B/401, AMBIKA DARSHAN CHITABHAI PATEL ROAD, KANDIVALI(E)
City : MUMBAI (SUBURBAN) District : MUMBAI (SUBURBAN)
State : MAHARASHTRA Country : INDIA
Pincode : 400101
Date of birth : 22/01/1983 Tel No (Res) : Clinic No :
Mobile No : 9823780553 Email Id : sushiltripathi@hotmail.co.uk  
Total Obtained Credits Points : 0
Remaining Credits Points : 0
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.DPABD, AMRAVATIMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK2006  
2.M.D.(Paediatrics)BJMC PUNEMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK20102446/201002/08/2010
3.D.M.(Cardiology)GSMC MUMBAIMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK20142814/201413/10/2014
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : DU41285825
Receipt Date : 17/02/2016
   I have uploaded following documents:
1.Latest Passport size Photograph
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 : 09/02/2016
    Applicant signature               


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