Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC202255633 Date : 18/03/2022
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)  LANJEWAR SHUBHANGI PRAKASHRAO
Registration No:  2002031755   Registration Date : 27/03/2002   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 : Ms. LANJEWAR SHUBHANGI PRAKASHRAO
Name of Father : Mr. LANJEWAR PRAKASHRAO .
Name of Mother : Mrs. LANJEWAR SANJAYA PRAKASHRAO
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : SHREE NIVAS SINGHANIYA NAGAR NEAR POOJA APPARTMENT WADGAON AARNI ROAD .
City : YAVATMAL District : YAVATMAL
State : MAHARASHTRA Country : INDIA
Pincode : 445001
Date of birth : 31/05/1978 Tel No (Res) : +918888720773 Clinic No : 8888720773
Mobile No : 8888720773 Email Id : nambadekar@yahoo.com  
Total Obtained Credits Points : 0
Remaining Credits Points : 0
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.Dip. Ophth. Med. & Surg.C.P.S.BOMBAYC.P.S. BOMBAY20061104/201309/05/2013
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : 202207703052846
Receipt Date : 19/03/2022
   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.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 : 18/03/2022
    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