Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202167851
Date :
28/12/2021
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)
TALE SARIKA PHOOLCHAND
Registration No:
2003052132
Registration Date :
12/05/2003
Valid upto Date :
28/02/2027
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.
TALE
SARIKA
PHOOLCHAND
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
B-301, SHREENATH HERMITAGE CO HSG, SOC, SOMESHWARWADI PASHAN, TAL-DIST-PUNE,
City
:
PUNE
District
:
PUNE
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
411008
Date of birth
:
27/05/1980
Tel No (Res)
:
Clinic No
:
Mobile No
:
9960839271
Email Id
:
shindesarika15@gmail.com
Total Obtained Credits Points
:
38
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
GSMC MUMBAI
MUMBAI UNIVERSITY
2003
2.
Dip. Child Health
C.P.S.BOMBAY
C.P.S. BOMBAY
2007
0717/2009
17/03/2009
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202136292368234
Receipt Date
:
29/12/2021
I have uploaded following documents:
1.
Latest Passport size Photograph
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 :
28/12/2021
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.