Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202215323
Date :
12/01/2022
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)
HUSSAIN SAIFUDDIN GULAM
Registration No:
52225
Registration Date :
17/05/1984
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.
HUSSAIN
SAIFUDDIN
GULAM
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
HAKIMI VILLA,B-14 B-15, BATUL PARK, WASHIM BY-PASS ROAD, DIST-AKOLA
City
:
AKOLA
District
:
AKOLA
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
444001
Date of birth
:
17/02/1960
Tel No (Res)
:
Clinic No
:
0724-243-4774
Mobile No
:
9422864976
Email Id
:
dr.hussain110@gmail.com
Total Obtained Credits Points
:
33
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
GOVERNMENT MEDICAL COLLEGE, NAGPUR
NAGPUR UNIVERSITY
1984
2.
M.S. (Ophthalmology)
GOVERNMENT MEDICAL COLLEGE, NAGPUR
NAGPUR UNIVERSITY
1987
6216
25/09/1987
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202201251797738
Receipt Date
:
13/01/2022
I have uploaded following documents:
1.
Latest Passport size Photograph
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 :
12/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.