Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC20240010189 Date : 05/03/2024
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)  PATIL JAYVARDHAN TUKARAM
Registration No:  2008093218   Registration Date : 02/09/2008   Valid upto Date :02/09/2028
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. PATIL JAYVARDHAN TUKARAM
Name of Father : Mr. PATIL TUKARAM RAGHUNATH
Name of Mother : Mrs. PATIL GIRIBAI TUKARAM
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : AT-POST-ANKALKHOP (ZENDA CHOWK),DIST- SANGLI,PIN-416316
City : PALUS District : SANGLI
State : MAHARASHTRA Country : INDIA
Pincode : 416316
Date of birth : 15/10/1984 Tel No (Res) : Clinic No :
Mobile No : 8424047755 Email Id : drjayvardhanpatil96@gmail.com  
Total Obtained Credits Points : 26
Remaining Credits Points : 4
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.BHARATI VIDYAPEETH UNIVERSITY MEDICAL COLLEGE, PUNEBHARATI VIDYAPEETH DEEMED UNIVERSITY, PUNE2008  
2.Dip. Ortho.KIMS, KARADKRISHNA INSTITUTE OF MEDICAL SCIENCES UNIVERSITY (DEEMED), KARAD20124207/201229/11/2012
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : 0806867125
Receipt Date : 06/03/2024
   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.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 : 05/03/2024
    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