Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20221028680
Date :
12/10/2022
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)
CHORE PRATIK DNYANESHWAR
Registration No:
2017073178
Registration Date :
14/07/2017
Valid upto Date :
14/07/2027
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.
CHORE
PRATIK
DNYANESHWAR
Name of Father
:
Mr.
CHORE
DNYANESHWAR
MAROTRAO
Name of Mother
:
Mrs.
CHORE
PRAVINA
DNYANESHWAR
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
AT POST BENODA TAL - WARUD DIST - AMRAVATI
City
:
WARUD
District
:
AMRAVATI
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
444908
Date of birth
:
06/04/1993
Tel No (Res)
:
09403174974
Clinic No
:
Mobile No
:
9403174974
Email Id
:
pratikchore94@gmail.com
Total Obtained Credits Points
:
4
Remaining Credits Points
:
26
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
GOVERNMENT MEDICAL COLLEGE, AKOLA
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2017
2.
D.N.B. (Anaesthesiology)
N.B.E. NEW DELHI
N.B.E. NEW DELHI
2022
1291/2023
24/03/2023
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
IGAOLRJMZ8
Receipt Date
:
13/10/2022
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Self attested photocopy of MMC Registration Certificate
3.
Original Undertaking
4.
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 :
12/10/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.