Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202203967
Date :
04/01/2022
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)
GALDHAR ASHWINI NIVRUTTI
Registration No:
2001021003
Registration Date :
26/02/2001
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.
GALDHAR
ASHWINI
NIVRUTTI
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
B-302, ARCHIT RUTURANG APARTMENT, OPP NAKSHTRA LAWNS, PIPELINE ROAD, OFF GANGAPUR ROAD, NASHIK
City
:
NASHIK
District
:
NASHIK
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
422013
Date of birth
:
21/07/1978
Tel No (Res)
:
Clinic No
:
Mobile No
:
9881301808
Email Id
:
asp1404@gmail.com
Total Obtained Credits Points
:
35
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
BJMC PUNE
POONA UNIVERSITY
2001
2.
Dip. (Obst. & Gynae.)
GSMC MUMBAI
MUMBAI UNIVERSITY
2005
0444/2012
03/02/2012
3.
F.C.P.S. (Mid. & Gynae.)
C.P.S.BOMBAY
C.P.S. BOMBAY
2006
0446/2012
03/02/2012
4.
D.N.B. (Obst. & Gynae.)
N.B.E. NEW DELHI
N.B.E. NEW DELHI
2013
0589/2023
21/02/2023
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202200406906902
Receipt Date
:
05/01/2022
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 :
04/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.