Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC202131075 Date : 18/06/2021
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)  PARATE SHAILESH VASANTRAO
Registration No:  2006020855   Registration Date : 14/02/2006   Valid upto Date :14/02/2026
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. PARATE SHAILESH VASANTRAO
Name of Father : Mr. PARATE VASANTRAO SHANKARRAO
Name of Mother : Mrs. PARATE LATA VASANTRAO
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : GAJANAN NAGAR, WARD NO.2, PO.MANAS MANDIR, DIST. WARDHA
City : WARDHA District : WARDHA
State : MAHARASHTRA Country : INDIA
Pincode : 442001
Date of birth : 27/10/1982 Tel No (Res) : Clinic No : 9007562292
Mobile No : 9007562292 Email Id : drshaileshparate@gmail.com  
Total Obtained Credits Points : 0
Remaining Credits Points : 30
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.JNMC, WARDHAMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK2006  
2.M.D.(Forensic Medicine)M.S RAMAIAH BANGALORRAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA20111646/201123/06/2011
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : IGALIRJVI5
Receipt Date : 19/06/2021
   I have uploaded following documents:
1.Latest Passport size Photograph
2.Photocopy Of Additional Qualification certificate of MMC
3.Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
4.Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
5.Self attested photocopy of MMC Registration Certificate
6.Original Undertaking
7.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 : 18/06/2021
    Applicant signature               


NOTE:- You need to submit the print out of original submitted Renewal Application form With original Affidavit & Indemntity Bond to MMC office.

  ______________________________ FOR OFFICE USE ONLY ______________________________
 
CHECKLIST for submission of documents 
1.Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary) Yes No
2.Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary) Yes No
  
Provisional Verification Final Verification
Name Name
Signature


 Signature
Date Date