Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230065212
Date :
19/10/2023
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)
BANSOD TUSHAR ANIL
Registration No:
2018105365
Registration Date :
23/10/2018
Valid upto Date :
23/10/2028
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.
BANSOD
TUSHAR
ANIL
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
HOUSE NO.221, LUMBINI COLONY, NEAR KISAN DANTMANJAN COMPANY, LAWRI UMRI, TALUKA - SAKOLI, DIST - BHANDARA - 441802 ,
City
:
SAKOLI
District
:
BHANDARA
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
440027
Date of birth
:
27/09/1993
Tel No (Res)
:
08698726263
Clinic No
:
Mobile No
:
9967190696
Email Id
:
tusharbansod1993@gmail.com
Total Obtained Credits Points
:
10
Remaining Credits Points
:
20
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
RGMC THANE
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2018
2.
M.S.(Obst. & Gynae.)
INDIRA GANDHI MEDICAL COLLEGE & HOSPITAL, NAGPUR
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2023
5465/2023
21/11/2023
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
IGAQINRKA3
Receipt Date
:
21/10/2023
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 :
19/10/2023
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.