Application No :  MMC202244471	Date : 24/02/2022
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)  PATHAK VIVEK RAMDAS
Registration No:  56298   Registration Date : 07/04/1986   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.	PATHAK	VIVEK	RAMDAS
Name of Father	:	Mr.
Name of Mother	:	Mrs.
In Case of Married Women
Maiden Name	:	-

RESEDENTIAL ADDRESS	:	AT POST TAL-NAWAPUR, DIST-NANDURBAR
City	:	NANDURBAR	District	:	NANDURBAR
State	:	MAHARASHTRA	Country	:	INDIA
Pincode	:	425418

Date of birth	:	04/10/1962	Tel No (Res)	:		Clinic No	:
Mobile No	:	9421533149	Email Id	:	vivekpathak1962@gmail.com

Pariticulars Of Payment
Payment Mode	:	Online Payment
Receipt No	:	IGANBOTZA9
Receipt Date	:	25/02/2022

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 : 24/02/2022

Applicant signature