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

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