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 QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.DR.D.Y. PATIL MEDICAL COLLEGE, KOLHAPURSHIVAJI UNIVERSITY, KOLHAPUR1995  
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.