Maharashtra Medical Council, Mumbai
Application form  for Permanent  Registration for Indian
 nationals having qualified from foreign institutions
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 2nd Floor,
Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sir,
I request you to register my name under the Maharashtra Medical Council Act., 1965 and further to issue certificate of registration to me. My particulars are as follows :
Application No.: MMC20230058806 Application Date :22/09/2023
  Prefix Sur Name First Name Middle Name
Name of Applicant : Mr. S DAS ARJUN
Name of Father : Mr. S SIVADAS
Name of Mother : Mrs. SREEJA S DAS
In Case of Married Women
Maiden Name :
Name of Husband : 0
Present Address For Communication : FLAT NO. 1504, 15TH FLOOR, PLATINUM CASA MILLENNIA, BUILDING NO.2, MANGALMURTY CHS OFF, D N NAGAR, ANDHERI WEST
City/Taluka : MUMBAI (SUBURBAN) District : MUMBAI (SUBURBAN)
State : MAHARASHTRA Pincode : 400053
Mobile No : 8086531669 Email Id : arjun.thinkal@gmail.com
Residential No : Clinic No :
Category : Nationality  
Date of birth : 26/05/1989   :  
Gender : M Marrital Status : M
10th Class/Matric/ High School
School Name : TRINITY LYCEUM School Address : KOLLAM
Board Name : ICSE Board Address : KERALA
Roll No : 23 Result : Yes
Certificate No : 38139 Certificate Date : 14/05/2005
Marks Marks (Obtained/Total) : 432 /  600 Percentage : 72
           
11th Class
School Name : S N TRUST HIGHER SECONDAR SCHOOL School Address : KERALA
Board Name : Board Address :
Roll No : 22 Result : Yes
Certificate No : 00 Certificate Date : 14/05/2006
Marks (Obtained/Total) : 224 /  420 Percentage : 43
           
12th Class/Intermediate or 10+2
School Name : S N TRUST HIGHER SECONDARY SCHOOL School Address : KOLLAM
Board Name : GOVERMENT OF KERALA BOARD OF HIGHER SECONDARY SCHOOL Board Address : KERALA
Roll No : 33 Result : Yes
Certificate No : 30513 Certificate Date : 22/05/2007
Marks : 477 /  600 Percentage : 79.05
Sr No.SubjectsMaximum MarksObtained Marks% ResultPass/Fail
1 English1008484P
2 Physics1007777P
3 Chemistry1009494P
4 Biology1008686P
MEDICAL QUALIFICATION:
Name of Institute : WUHAN UNIVERISTY Address of Institute : CHINA
Registration Number/ (OVIR NO.) : 00 Address of SENTRALNIYA OVIR (Registration Deptt.-OVIR) (Ministry of Foreign Affairs or Interior Ministry City) : CHINA
Registration Valid from   30/10/2014 Registration Valid upto   30/10/2024
Medium of instructions : ENGLISH      
Have You done any part of your medical course in india, or any country than where you have obtained Medical degree as mention in application, If Yes ,its duration and Location :  N
PASSPORT DETAILS:
Passport No : G4122997    
Date of issue : 27/07/2007 Place of issue : KERALA
Address as on passport : THINKAL, KADAPPAKKADA, P.O, KOLLAM , KERALA- 691008
Visa issued by (name of Country) : INDIA Nature of Visa : STUDENT
Date of Validity from : 27/07/2007 To : 26/07/2017
Date of leaving India : 11/09/2007 Date of returning to india : 31/07/2012
Did You ever Change/Loss the passport due to any reason :
           
SCREENING TEST PARTICULARS:
Name of Board : National Board of Examination New Delhi. (Ministry of Health, Government of India)
Date of passing : 30/09/2012 Roll no : 122032301
Marks obtained : 188 Out of : 300
INTERNSHIP TRAINING PARTICULARS:
Name of Training Institute : GOVERNMENT GENERAL HOSPITAL Address : TRIVANDRUM
State : KERALA Whether Recognized by MCI :
Date of Training from : 21/02/2013 To : 31/03/2014
Total Present in Days : 365      
NAME OF THE MEDICAL DEGREE / DIPLOMA OBTAINED AND UNIV. / LICENSING BODY WITH THE YEAR OF : WUHAN UNIVERSITY, CHINA
WHETHER SHE / HE HAS UNDERGONE PRACTICAL TRAINING BEFORE OR AFTER OBTAINING THE MEDICAL QUALIFICATION REQUIRED BY THE RULES OF THE CONCERNED FOREIGN COUNTRY : N
IF NOT, THEN HAS SHE / HE UNDERGONETHE PRESCRIBED TRAINING IN AN APPROVED HOSPITAL IN INDIA, GIVE DETAILS. : NA
WAS ANY MEDICAL COLLEGE / SCHOOL IN INDIA ATTENDED BEFORE DEPARTURE FROM INDIA, (GIVE NAMES OF PERIOD OF STUDY UNDERGONE AND EXAMINATION PASSED). : NA
IN THE LANGUAGE OF STUDY IN THE COUNTRY BE OTHER THAN ENGLISH, PLEASE INDICATE IF IT WAS STUDIED IN INDIA BEFORE DEPARTURE OR WAS STUDIED IN THAT COUNTRY. PLEASE INDICATE THE TIME TAKEN FOR THAT STUDY AND WHETHER ANY EXAMINATION WAS PASSED. : NA
DO THE MEDICAL EXAMINATION (S) PASSED IPSO FACTO ENTITLE ONE TO REGISTER IN THE COUNTRY IN WHICH THEY WERE TAKEN OR A SEPARATE EXAMINATION FOR REGISTRATION HAS TO BE PASSED. : NA
ARE YOU REGISTERED IN ANY FOREIGN COUNTRY? : N
 
     
   
I have enclosed following certificates in original alongwith their photocopies :
1.Passport size Photograph (2cm width and 2.5cm Height)
2.Candidate Sign (2.65cm width and 1.40cm Height)
3.Markssheet of SSC Exam ,Eleventh Class and HSSC
4.Passing Certificate of SSC and HSSC Examination board
5.Eligibility Certificate issued to the Candidate by MCI for admission to Undergraduate Medical Course in Abroad
6.Screening Test Result issued by National Board of Examination New Delhi. (Ministry of Health, Government of India)
7.All the pages of all the passports showing visa, the date of emigration and immigration from and to Foreign Country and India
8.Original Provisional Registration Certificate issued by MCI / any other State Medical Council
9.Internship Completion Certificate showing posting in various departments trained with
10.Notarised Affidavit on Non judicial Stamp Paper of Rs 100 /- with photograph for delay in applying for Permanent Registration- if the delay in applying for registration is more than 30days after completion of internship.
11.Letter from the Indian Embassy concerned that primary medical qualification as possessed by the candidate is a recognized qualification for enrollment as medical practitioner in the country in which the institution awarding the said qualification is situated.
12.Domicile Certificate issued by competent authority
13.M.B.B.S./M.D. physician degree Certificate issued by the recognized university

DECLARATION

I have carefully read the instructions. I certify that the particulars furnished above are true to the best of my knowledge and belief. I understand that Medical practice without a valid license is not official and lawful. I undertake to inform any change in my postal address due to change in my ordinary place of clinical practice. I read code of medical & Ethics Regulation of Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation 2002). I undertake to abide by these codes in their letter and spirit.
I am aware of legal consequences of misleading the Maharashtra Medical Council.
Date:
Place (Signature of the Applicant & Name)

MAHARASHTRA MEDICAL COUNCIL
189/A, Anand Complex, 2nd Floor, Sane Guruji Marg, Arthur Road Naka, Chinchpokali (W), Mumbai - 400 011. Tel. : 022-2307 2464 / 022-2308 3043 Website : www.maharashtramedicalcouncil.in
DECLARATION
(As per Indian Medical Council {Professional Conduct, Etiquette and Ethics} Regulations 2002)
             At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same.
1.  I solemnly pledge myself to consecrate my life to service of humanity.
2.  I will maintain the utmost respect for human life from the time of conception.
3.   I will not permit considerations of religion, nationality, race party politics or social standing to intervene between my duty and my patient.
4. I will practice my profession with conscience and dignity.
5. The health of my patient will be my first consideration.
6. I will respect the secrets, which are confined in me.
7.  I will maintain by all means in power, the honour and noble traditions of medical profession.
8. I will treat my colleagues with all respect and dignity.
9.  I shall abide by the Code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
I make these promises solemnly, freely and upon my honour
 
  Signature
Place
Address  
  Name
Date
  ______________________________ FOR OFFICE USE ONLY ______________________________
 
CHECKLIST for submission of documents 
1.Two Latest Passport size Photograph Yes No
2.Specimen Copy Signature Yes No
3.Markssheet of SSC Exam ,Eleventh Class and HSSC Yes No
4.Passing Certificate of SSC and HSSC Examination board Yes No
5.Eligibility Certificate issued to the Candidate by MCI for admission to Undergraduate Medical Course in Abroad Yes No
6.Screening Test Result issued by National Board of Examination New Delhi. (Ministry of Health, Government of India) Yes No
7.All the pages of all the passports showing visa, the date of emigration and immigration from and to Foreign Country and India Yes No
8.Original Provisional Registration Certificate issued by MCI / any other State Medical Council Yes No
9.Internship Completion Certificate showing posting in various departments trained with Yes No
10.Notarised Affidavit on Non judicial Stamp Paper of Rs 100 /- with photograph for delay in applying for Permanent Registration- if the delay in applying for registration is more than 30days after completion of internship. Yes No
11.Letter from the Indian Embassy concerned that primary medical qualification as possessed by the candidate is a recognized qualification for enrollment as medical practitioner in the country in which the institution awarding the said qualification is situated. Yes No
12.Domicile Certificate issued by competent authority Yes No
13.M.B.B.S./M.D. physician degree Certificate issued by the recognized university Yes No
  
Provisional Verification Final Verification
Name Name
Signature


 Signature
Date Date

Registration for foreign Medical Graduates committe for approval
Member 1 Member 2
Name Name
Signature


 Signature
Date Date