Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230058570
Date :
11/09/2023
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)
SIDDIQUI MAZHAR MOHD HAYAT
Registration No:
2013092907
Registration Date :
12/09/2013
Valid upto Date :
12/09/2028
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.
SIDDIQUI
MAZHAR MOHD
HAYAT
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
ROOM NO 41-A, BLDG NO-B-9,KHIRA NAGAR,SANTACRUZ WEST,MUMBAI
City
:
MUMBAI (SUBURBAN)
District
:
MUMBAI (SUBURBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400054
Date of birth
:
07/01/1988
Tel No (Res)
:
9821917865
Clinic No
:
9821917865
Mobile No
:
9821917865
Email Id
:
mahak_siddiqui2004@yahoo.com
Total Obtained Credits Points
:
41
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
PRAVARA MED COLLEGE
PRAVARA INSTITUTE OF MEDICAL SCIENCES DEEMED UNIVERSITY, LONI
2013
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202325420369285
Receipt Date
:
12/09/2023
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 :
11/09/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.