Application for Renewal Of Registration with the
Maharashtra Medical Council, Mumbai

Application No : MMC20230064723	Date : 17/10/2023
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) ARTI SUTAR .
Registration No: 2012051398 Registration Date : 28/05/2012 Valid upto Date :28/05/2017
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.	ARTI	SUTAR	.
Name of Father	:	Mr.	BABANRAO	SUTAR
Name of Mother	:	Mrs.	YASHODA	SUTAR
In Case of Married Women
Maiden Name	:	-

RESEDENTIAL ADDRESS	:	SHIVLING NAGAR ,BALSOND ,TAL+DIST: HINGOLI .
City	:	HINGOLI	District	:	HINGOLI
State	:	MAHARASHTRA	Country	:	INDIA
Pincode	:	431513

Date of birth	:	15/09/1986	Tel No (Res)	:		Clinic No	:
Mobile No	:	9920759830	Email Id	:	dr.artisutar@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.	GOVT.MC.MIRAJ	MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK	2012

Pariticulars Of Payment
Payment Mode	:	Online Payment
Receipt No	:	0740013166
Receipt Date	:	18/10/2023

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.	Self attested photocopy of MMC Registration Certificate
5.	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 : 17/10/2023

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