Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230055434
Date :
25/08/2023
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)
KAVALE HRUSHIKESH VILAS
Registration No:
2018084193
Registration Date :
13/08/2018
Valid upto Date :
13/08/2028
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
:
Mr.
KAVALE
HRUSHIKESH
VILAS
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
VIJAY HOSPITAL,OPPOSITE PHC,A.P MIRAJGAON TAL. KARJAT DIST. AHMEDNAGAR
City
:
KARJAT
District
:
AHMEDNAGAR
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
414401
Date of birth
:
20/11/1994
Tel No (Res)
:
Clinic No
:
Mobile No
:
8600321188
Email Id
:
hrushikavale@gmail.com
Total Obtained Credits Points
:
4
Remaining Credits Points
:
26
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
DR.D.Y.PATIL MEDICAL COLLEGE, HOSPITAL AND RESEARCH CENTRE,PIMPRI,PUNE
DR. D.Y. PATIL UNIVERSITY, PUNE
2018
2.
Dip.Medical Radiology & Electrology
C.P.S. MUMBAI
C.P.S. MUMBAI
2021
4609/2022
19/09/2022
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
0715685385
Receipt Date
:
30/08/2023
I have uploaded following documents:
1.
Latest Passport size Photograph
2.
Self attested photocopy of MMC Registration Certificate
3.
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 :
25/08/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.