Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202157489
Date :
22/11/2021
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)
BORKAR DURGA SHANKAR
Registration No:
2011113378
Registration Date :
28/11/2011
Valid upto Date :
28/11/2026
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
:
Ms.
BORKAR
DURGA
SHANKAR
Name of Father
:
Mr.
BORKAR
SHANKAR
SADASHIV
Name of Mother
:
Mrs.
BORKAR
SABITA
SHANKAR
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
A-7, NALANDA GARDEN, OPP. MAULI MANGAL KARYALAYA, BANER ROAD,
City
:
PUNE
District
:
PUNE
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
411045
Date of birth
:
23/04/1979
Tel No (Res)
:
Clinic No
:
Mobile No
:
9767195092
Email Id
:
dr.durgaborker@gmail.com
Total Obtained Credits Points
:
30
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
GOA MEDICAL COLLEGE, PANAJI
GOA UNIVERSITY
2002
2.
M.D.(Anaesthesiology)
GOA MEDICAL COLLEGE, PANAJI
GOA UNIVERSITY
2005
1021/2012
16/03/2012
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202132650089608
Receipt Date
:
23/11/2021
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
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 :
22/11/2021
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.