Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230058668
Date :
12/09/2023
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)
NANAVATI HARDIK NILESH
Registration No:
2018063304
Registration Date :
28/06/2018
Valid upto Date :
28/06/2028
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
:
Mr.
NANAVATI
HARDIK
NILESH
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
A-401, AMBIKA APARTMENT, V.B. PHADKE ROAD, (ABOVE JANAKALYAN BANK), MULUND (E), MUMBAI
City
:
MUMBAI (SUBURBAN)
District
:
MUMBAI (SUBURBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400081
Date of birth
:
21/12/1994
Tel No (Res)
:
Clinic No
:
Mobile No
:
9920200285
Email Id
:
hardiknanavati1994@gmail.com
Total Obtained Credits Points
:
24
Remaining Credits Points
:
6
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
KJ SOMAIYYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAI
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2018
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202325593081507
Receipt Date
:
13/09/2023
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 :
12/09/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.