Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202225957
Date :
25/01/2022
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)
PETHE NIRMAL SHANKAR
Registration No:
38719
Registration Date :
05/01/1978
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.
PETHE
NIRMAL
SHANKAR
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
C 40 GAIKWAD HEIGHTS, NEXT TO CROMA 127/1B SEASONS ROAD,AUNDH .
City
:
PUNE
District
:
PUNE
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
411007
Date of birth
:
28/03/1953
Tel No (Res)
:
9423523676
Clinic No
:
Mobile No
:
9822476554
Email Id
:
nirmalpethe@yahoo.co.in
Total Obtained Credits Points
:
7
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
BJMC PUNE
POONA UNIVERSITY
1977
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202202667101163
Receipt Date
:
27/01/2022
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 :
25/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.