Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202207248
Date :
06/01/2022
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)
MODASE VINOD JAWAHARLAL
Registration No:
78477
Registration Date :
17/01/1996
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
:
Mr.
MODASE
VINOD
JAWAHARLAL
Name of Father
:
Mr.
MODASE
JAWAHARLAL
GULABCHAND
Name of Mother
:
Mrs.
MODASE
NALINI
JAWAHARLAL
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
MODASE HOSPITAL & DENTAL CLINIC, KRISHNA NAGAR, HIGHWAY SERVICE ROAD, DIST-SATARA
City
:
SATARA
District
:
SATARA
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
415003
Date of birth
:
24/09/1973
Tel No (Res)
:
Clinic No
:
Mobile No
:
9823079445
Email Id
:
modase28@yahoo.co.in
Total Obtained Credits Points
:
13
Remaining Credits Points
:
17
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
DR.D.Y. PATIL MEDICAL COLLEGE, KOLHAPUR
SHIVAJI UNIVERSITY, KOLHAPUR
1995
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202200721869619
Receipt Date
:
10/01/2022
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Original Undertaking
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 :
06/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.