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.: MMC20240006360	Application Date :10/02/2024

		Prefix	Sur Name	First Name	Middle Name
Name of Applicant	:	Ms.	DIAS	SENTICIA
Name of Father	:	Mr.	DIAS	ANTHONY
Name of Mother	:	Mrs.	DIAS	GLADYS
	In Case of Married Women
Maiden Name	:
Name of Husband	:	0

Present Address For Communication	:	LODHA AMARA ,WING -32/B, 11TH FLOOR, FLAT - 1102, KOLSHET ROAD, THANE WEST
City/Taluka	:	THANE	District	:	THANE
State	:	MAHARASHTRA	Pincode	:	400607
Mobile No	:	7447773186	Email Id	:	senticia@gmail.com
Residential No	:		Clinic No	:
Category	:		Nationality

Date of birth	:	01/11/1983		:
Gender	:	F	Marrital Status	:	M

10th Class/Matric/ High School

School Name	:	GURU NANAK ENGLISH HIGH SCHOOL	School Address	:	KALYAN
Board Name	:	PUNE	Board Address	:	PUNE
Roll No	:	23	Result	:	Yes
Certificate No	:	01964	Certificate Date	:	14/06/2000
Marks Marks (Obtained/Total)	:	474 / 750	Percentage	:	63.20

11th Class

School Name	:	K M AGARWAL COLLEGE OF ARTS, COMMERCE & SCIENCE	School Address	:	KALYAN
Board Name	:		Board Address	:
Roll No	:	210	Result	:	Yes
Certificate No	:	188	Certificate Date	:	16/04/2001
Marks (Obtained/Total)	:	297 / 600	Percentage	:	58.23

12th Class/Intermediate or 10+2

School Name

R K TALREJA COLLEGE OF ARTS, SCIENCE & COMMERCE

School Address

ULHASNAGAR

Board Name

PUNE

Board Address

PUNE

Roll No

Result

Yes

Certificate No

00860

Certificate Date

11/02/2002

Marks

373 / 600

Percentage

62.17

Sr No.	Subjects	Maximum Marks	Obtained Marks	% Result	Pass/Fail
1	English	100	62	62	P
2	Physics	100	62	62	P
3	Chemistry	100	58	58	P
4	Biology	100	64	64	P

MEDICAL QUALIFICATION:

Name of Institute	:	ODESSA STATE MEDICAL UNIVERSITY	Address of Institute	:	UKRAINE
Registration Number/ (OVIR NO.)	:	001	Address of SENTRALNIYA OVIR (Registration Deptt.-OVIR) (Ministry of Foreign Affairs or Interior Ministry City)	:	UKRAINE
Registration Valid from		12/10/2010	Registration Valid upto		12/10/2030
Medium of instructions	:	ENLGLISH
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	:	B2471568
Date of issue	:	14/08/2000	Place of issue	:	THANE
Address as on passport	:	AMBIKA SADAN, RAMBAUG LANE -A, KALYAN (W), THANE
Visa issued by (name of Country)	:	INDIA	Nature of Visa	:	STUDENT
Date of Validity from	:	14/08/2000	To	:	13/08/2010
Date of leaving India	:	10/10/2002	Date of returning to india	:	01/07/2008
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	:	30/04/2009	Roll no	:	90011755
Marks obtained	:	158	Out of	:	300

INTERNSHIP TRAINING PARTICULARS:

Name of Training Institute

GRANT MEDICAL COLLEGE & SIR J J GROUP OF HOSPITAL

Address

MUMBAI

State

MAHARASHTRA

Whether Recognized by MCI

Yes

Date of Training from

17/07/2009

05/08/2010

Total Present in Days

365

NAME OF THE MEDICAL DEGREE / DIPLOMA OBTAINED AND UNIV. / LICENSING BODY WITH THE YEAR OF	:	ODESSA STATE MEDICAL UNIVERSITY, UKRAINE
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	Signature
Address
	Name
Date	Name

______________________________ 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