Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202262046
Date :
03/04/2022
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)
MUTHE MAYUR KIRAN
Registration No:
2001031730
Registration Date :
22/03/2001
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.
MUTHE
MAYUR
KIRAN
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
32/69, VISANJI NAGAR, DIST-JALGAON
City
:
JALGAON
District
:
JALGAON
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
425001
Date of birth
:
18/06/1978
Tel No (Res)
:
Clinic No
:
Mobile No
:
9765285160
Email Id
:
mayurmuthe@gmail.com
Total Obtained Credits Points
:
46
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
MGMMC, NAVI MUMBAI
MUMBAI UNIVERSITY
2001
2.
M.D. (Psychiatry)
BJMC PUNE
POONA UNIVERSITY
2005
24751
02/06/2006
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202209397356463
Receipt Date
:
04/04/2022
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 :
03/04/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.