Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20221024571
Date :
19/09/2022
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)
CHANDANSHIVE EKANATH IRAPPA
Registration No:
57917
Registration Date :
19/02/1987
Valid upto Date :
31/05/2027
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.
CHANDANSHIVE
EKANATH
IRAPPA
Name of Father
:
Mr.
CHANDANSHIVE
IRAPPA
NARAYAN
Name of Mother
:
Mrs.
CHANDANSHIVE
ULISHA
IRAPPA
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
SUB DISTRICT HOSPITAL, INDAPUR, DIST- PUNE
City
:
INDAPUR
District
:
PUNE
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
413106
Date of birth
:
01/06/1961
Tel No (Res)
:
Clinic No
:
Mobile No
:
7378422727
Email Id
:
madhurichandanshive80@gmail.com
Total Obtained Credits Points
:
86
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
DR VAISHAMPAYAN MEMORIAL MEDICAL COLLEGE, SOLAPUR
SHIVAJI UNIVERSITY, KOLHAPUR
1986
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202226252990637
Receipt Date
:
20/09/2022
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
3.
Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
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 :
19/09/2022
Applicant signature
NOTE:- You need to submit the print out of original submitted Renewal Application form With original Affidavit & Indemntity Bond to MMC office.
______________________________
FOR OFFICE USE ONLY
______________________________
CHECKLIST for submission of documents
1.
Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
Yes
No
2.
Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
Yes
No
Provisional Verification
Final Verification
Name
Name
Signature
Signature
Date
Date