Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20230066197
Date :
26/10/2023
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)
SHINDE KAUSHALYA PRAKASHRAO
Registration No:
2013051751
Registration Date :
22/05/2013
Valid upto Date :
22/05/2028
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
:
Ms.
SHINDE
KAUSHALYA
PRAKASHRAO
Name of Father
:
Mr.
SHINDE
PRAKASHRAO
VISHWANATH
Name of Mother
:
Mrs.
SHINDE
SHANTABAI
PRAKASHRAO
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
C/O. DR. S.Y. JADHAV , YESHWANT CHILDREN HOSPITAL , SHAHUNAGAR, TAL. DIST. BEED
City
:
BEED
District
:
BEED
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
431122
Date of birth
:
24/06/1986
Tel No (Res)
:
Clinic No
:
Mobile No
:
9511274800
Email Id
:
kaushalyajadhav04@gmail.com
Total Obtained Credits Points
:
34
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
SHRI V.N.MEDICAL COLLEGE,YAVATMAL
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2013
2.
Dip. Child Health
C.P.S. MUMBAI
C.P.S. MUMBAI
2016
1048/2019
16/04/2019
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202329946717987
Receipt Date
:
27/10/2023
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)
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 :
26/10/2023
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