Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230043362
Date :
04/07/2023
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)
NAIK ARCHANA BALAJIRAO
Registration No:
2013062168
Registration Date :
12/06/2013
Valid upto Date :
12/06/2028
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.
NAIK
ARCHANA
BALAJIRAO
Name of Father
:
Mr.
NAIK
BALAJIRAO
MAROTIRAO
Name of Mother
:
Mrs.
NAIK
HEMLATA
BALAJIRAO
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
AT - POST : KALAMBAR (DEVACHE) , .
City
:
MUKHED
District
:
NANDED
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
431715
Date of birth
:
05/06/1988
Tel No (Res)
:
Clinic No
:
0311
Mobile No
:
7506960773
Email Id
:
archu.naik56@gmail.com
Total Obtained Credits Points
:
23
Remaining Credits Points
:
7
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
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2013
2.
Dip. (Gynae. & Obst.)
C.P.S. MUMBAI
C.P.S. MUMBAI
2017
2146/2018
08/08/2018
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202318575976065
Receipt Date
:
05/07/2023
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Original Undertaking
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 :
04/07/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.