Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230053005
Date :
13/08/2023
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)
SHANA SOOD .
Registration No:
2013030402
Registration Date :
05/03/2013
Valid upto Date :
05/03/2028
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.
SHANA
SOOD
.
Name of Father
:
Mr.
RAVI
KUMAR
SOOD
Name of Mother
:
Mrs.
ANJANA
SOOD
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
103/A, SANDEEP SAROVAR, MHADA, 4 BUNGLOWS, ANDHERI (W), MUMBAI
City
:
MUMBAI (SUBURBAN)
District
:
MUMBAI (SUBURBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400053
Date of birth
:
14/07/1989
Tel No (Res)
:
Clinic No
:
Mobile No
:
9790156092
Email Id
:
shanasood14@gmail.com
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.
BHARATI VIDYAPEETH DEEMED UNIVERSITY MEDICAL COLLEGE & HOSPITAL, SANGLI
BHARATI VIDYAPEETH DEEMED UNIVERSITY, PUNE
2013
2.
D.N.B. (Ophthalmology)
N.B.E. NEW DELHI
N.B.E. NEW DELHI
2017
0367/2018
01/02/2018
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202322522722892
Receipt Date
:
14/08/2023
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.
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 :
13/08/2023
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