Application for Renewal Of Registration with the
Maharashtra Medical Council, Mumbai

Application No : MMC202248455	Date : 02/03/2022
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) ASOLE SURESH YOGAJI
Registration No: 79075 Registration Date : 01/03/1996 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.	ASOLE	SURESH	YOGAJI
Name of Father	:	Mr.	ASOLE	YOGAJI	KANHOJI
Name of Mother	:	Mrs.	ASOLE	KONDABAI	YOGAJI
In Case of Married Women
Maiden Name	:	-

RESEDENTIAL ADDRESS	:	DR ASOLE S Y C/O SHREE N FTHAKARE MOHAN BHAJI BHANDAR CHOWK TAPDIA NAGAR AKOLA
City	:	AKOLA	District	:	AKOLA
State	:	MAHARASHTRA	Country	:	INDIA
Pincode	:	444001

Date of birth	:	06/06/1971	Tel No (Res)	:		Clinic No	:
Mobile No	:	8007959629	Email Id	:	sureshasole1971@gmail.com

Is Exemption	:	Yes
Exemption from earning credit points Category	:	DIRECTOR OF HEALTH SERVICES

Qualification Details

	Details of Qualification	Name of College	University	Passing Year	Certificate No	Certificate Date
1.	M.B.B.S.	DR. SHANKARRAO CHAVAN GOVT. MEDICAL COLLEGE, NANDED	DR. BABASAHEB AMBEDKAR MARATHWADA UNIVERSITY	1996		0

Pariticulars Of Payment
Payment Mode	:	Online Payment
Receipt No	:	IGANCRHIS4
Receipt Date	:	04/03/2022

I have uploaded following documents:

1.	Latest Passport size Photograph
2.	Photocopy Of Additional Qualification certificate of MMC
3.	Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
4.	Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
5.	Self attested photocopy of MMC Registration Certificate
6.	Original Undertaking
7.	Proof Of Exemption

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 : 02/03/2022

Applicant signature

NOTE:- You need to submit the print out of original submitted Renewal Application form With original Affidavit & Indemntity Bond to MMC office.

______________________________ FOR OFFICE USE ONLY ______________________________

CHECKLIST for submission of documents

1.	Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)	Yes	No
2.	Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)	Yes	No


Provisional Verification	Final Verification
Name	Name
Signature	Signature
Date	Date