Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC202252067 Date : 09/03/2022
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)  MESHRAM PRIYANKA BALKRISHNA
Registration No:  2016083259   Registration Date : 31/08/2016   Valid upto Date :31/08/2026
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 : Ms. MESHRAM PRIYANKA BALKRISHNA
Name of Father : Mr. MESHRAM BALKRISHNA MAHADEO
Name of Mother : Mrs. MESHRAM MEENA BALKRISHNA
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : NEAR MANDHARE HOUSE. AT BHOJAPUR, BHOJAPUR, CITY - BHANDARA, MAHARASHTRA
City : BHANDARA District : BHANDARA
State : MAHARASHTRA Country : INDIA
Pincode : 441906
Date of birth : 25/05/1991 Tel No (Res) : 9322235996 Clinic No :
Mobile No : 9322235996 Email Id : mayurmeshram8888@gmail.com  
Total Obtained Credits Points : 0
Remaining Credits Points : 30
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.MGIMS, SEVAGRAMMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK2016  
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : 202206974286267
Receipt Date : 11/03/2022
   I have uploaded following documents:
1.Latest Passport size Photograph
2.Original Notarised Affidavit on non judicial stamp paper (Note: If more than 3 months delay then necessary)
3.Original Notarised Indemntity bond on non judicial stamp paper (Note: If more than 3 months delay then necessary)
4.Self attested photocopy of MMC Registration Certificate
5.Original Undertaking
6.Self attested photocopy of Aadhar Card
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 : 09/03/2022
    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