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 QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.GSMC MUMBAIMUMBAI UNIVERSITY2003  
2.Dip. Child HealthC.P.S.BOMBAYC.P.S. BOMBAY20070717/200917/03/2009
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.