Application for Renewal Of Registration with the
Maharashtra Medical Council, Mumbai

Application No : MMC20221025571	Date : 24/09/2022
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) MUGDIYA SUSHIL SHANTILALJI
Registration No: 2002042027 Registration Date : 12/04/2002 Valid upto Date :28/02/2017
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.	MUGDIYA	SUSHIL	SHANTILALJI
Name of Father	:	Mr.	MUGDIYA	SHANTILALJI
Name of Mother	:	Mrs.	MUGDIYA	KALPANA	SHANTILALJI
In Case of Married Women
Maiden Name	:	-

RESEDENTIAL ADDRESS	:	ANAND BALRUGNALAYASAMTACOLONY MAJALGAON
City	:	BEED	District	:	BEED
State	:	MAHARASHTRA	Country	:	INDIA
Pincode	:	431131

Date of birth	:	15/12/1979	Tel No (Res)	:		Clinic No	:
Mobile No	:	8007595660	Email Id	:	drsushilmugdiya79@gmail.com

Total Obtained Credits Points	:	18
Remaining Credits Points	:	12

Qualification Details

	Details of Qualification	Name of College	University	Passing Year	Certificate No	Certificate Date
1.	M.B.B.S.	JNMC NAGPUR	NAGPUR UNIVERSITY	2002

Pariticulars Of Payment
Payment Mode	:	Online Payment
Receipt No	:	202226703497474
Receipt Date	:	26/09/2022

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)
4.	Self attested photocopy of MMC Registration Certificate
5.	Original Undertaking
6.	Self attested photocopy of Aadhar Card

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 : 24/09/2022

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