Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC202119194 Date : 03/05/2021
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)  PAWAL SAMBHAJI KANTRAO
Registration No:  2006042286   Registration Date : 19/04/2006   Valid upto Date :19/04/2026
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. PAWAL SAMBHAJI KANTRAO
Name of Father : Mr. PAWAL KANTRAO NAGORAO
Name of Mother : Mrs. PAWAL MANGAL KANTRAO
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : AT-TANDALWADI HAWELI, POST-SHIRASMARG,
City : BEED District : BEED
State : MAHARASHTRA Country : INDIA
Pincode : 431122
Date of birth : 13/09/1982 Tel No (Res) : 8381076535 Clinic No : 8600924940
Mobile No : 8600924940 Email Id : sambhajipawal@gmail.com  
Total Obtained Credits Points : 22
Remaining Credits Points : 8
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.LTMC MUMBAIMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK2006  
2.M.D.(Radio Diagnosis)GSMC MUMBAIMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK20104000/201022/12/2010
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : 202112326725501
Receipt Date : 04/05/2021
   I have uploaded following documents:
1.Latest Passport size Photograph
2.Photocopy Of Additional Qualification certificate of MMC
3.Self attested photocopy of MMC Registration Certificate
4.Original Undertaking
5.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 : 03/05/2021
    Applicant signature               


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