Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230000979
Date :
06/01/2023
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)
WASNIK MADHURA NITIN
Registration No:
2017104908
Registration Date :
09/10/2017
Valid upto Date :
09/10/2027
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.
WASNIK
MADHURA
NITIN
Name of Father
:
Mr.
WASNIK
NITIN
BABURAO
Name of Mother
:
Mrs.
WASNIK
SHEEL
NITIN
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
119, HANUMAN NAGAR, NEAR MEDICAL SQUARE, NAGPUR
City
:
NAGPUR
District
:
NAGPUR
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
440024
Date of birth
:
08/09/1993
Tel No (Res)
:
Clinic No
:
Mobile No
:
9730759667
Email Id
:
madhurawasnik007@yahoo.in
Total Obtained Credits Points
:
0
Remaining Credits Points
:
30
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
NKPSMC NAGPUR
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2017
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202300692696997
Receipt Date
:
07/01/2023
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Self attested photocopy of MMC Registration Certificate
3.
Original Undertaking
4.
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 :
06/01/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.