Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC20240006813
Date :
13/02/2024
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)
AMIT PATEL
Registration No:
2016082482
Registration Date :
17/08/2016
Valid upto Date :
17/08/2026
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.
AMIT
PATEL
Name of Father
:
Mr.
PATEL
RAMJEET
PRASAD
Name of Mother
:
Mrs.
S
TULSI
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
497, MU BIRDPUR NO 12, TOLA KASHIPUR, DIST- SIDDHARTHNAGAR, UTTAR PRADESH, PIN- 272202
City
:
GORKHPUR
District
:
GORAKHPUR
State
:
UTTAR PRADESH
Country
:
INDIA
Pincode
:
272202
Date of birth
:
03/06/1991
Tel No (Res)
:
Clinic No
:
Mobile No
:
8956373638
Email Id
:
bestamitpatel007@gmail.com
Total Obtained Credits Points
:
0
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
DPABD, AMRAVATI
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
2016
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202404490595438
Receipt Date
:
14/02/2024
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.
Self attested photocopy of Aadhar Card
6.
Proof Of Exemption
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 :
13/02/2024
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