Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202217839
Date :
14/01/2022
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)
DESAI AMIT BHUPENDRA
Registration No:
39030
Registration Date :
30/01/1978
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.
DESAI
AMIT
BHUPENDRA
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
68 NETAJI SUBHASH ROAD 18, HEM PRABHA, 4TH FLOOR, MARINE DRIVE, MUMBAI
City
:
MUMBAI (URBAN)
District
:
MUMBAI (URBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400020
Date of birth
:
02/10/1953
Tel No (Res)
:
Clinic No
:
Mobile No
:
9819024520
Email Id
:
amitdesai_1953@yahoo.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.
GSMC MUMBAI
BOMBAY UNIVERSITY
1978
2.
Dip. (Psychological Medicine)
GSMC MUMBAI
BOMBAY UNIVERSITY
1979
3171/2011
08/12/2011
3.
M.D.(Psychological Medicine)
GSMC MUMBAI
BOMBAY UNIVERSITY
1980
3171/2011
08/12/2011
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202201437082610
Receipt Date
:
15/01/2022
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 :
14/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.