Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202003622
Date :
02/02/2020
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)
GAIKWAD SANTOSH KERBA
Registration No:
2005020912
Registration Date :
14/02/2005
Valid upto Date :
14/02/2020
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.
GAIKWAD
SANTOSH
KERBA
Name of Father
:
Mr.
GAIKWAD
KERBA
PANDHARINATH
Name of Mother
:
Mrs.
GAIKWAD
BAISABAI
KERBA
In Case of Married Women
Maiden Name
:
Ms.
RESEDENTIAL ADDRESS
:
A/P ADHEGAON, TAL-MADHA, SOLAPUR
City
:
SOLAPUR
District
:
SOLAPUR
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
413212
Date of birth
:
10/02/1978
Tel No (Res)
:
Clinic No
:
Mobile No
:
9922923924
Email Id
:
drsantoshgaikwad@gmail.com
Total Obtained Credits Points
:
34
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
BJMC PUNE
PUNE UNIVERSITY
2005
09/02/2005
14/02/2005
2.
Dip.Pub.Health
DR VAISHAMPAYAN MEMORIAL MEDICAL COLLEGE, SOLAPUR
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2020
2360/2021
02/06/2021
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202003374440249
Receipt Date
:
03/02/2020
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Self attested photocopy of MMC Registration Certificate
3.
Original Undertaking
4.
Self attested photocopy of Aadhar Card
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 :
02/02/2020
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.