MMC

Application Form for Provisional Registration(Who has passed MBBS from other state)

Personal Details

Name

Father's Name *

Mother's Name *

Marital Status *

Gender*

Maiden Name *

Husband's Name

Date of Birth

Contact Details

Full Residential Address in Maharashtra

Full Permanent Address

Please Select taluka as per your permanent address

Taluka

District

State

Country

Pin Code

Nationality

Mobile No

Email Id

Residential No

Clinic No

Internship Starting Date

Internship Completion Date

Other state Details

Provisional Reg No.

Provisional Reg Date

Prov Registration Validity Date

Purpose of Prov. Registration in Maharashtra

Authority Council Name*

State

NOC Letter No.

NOC Letter Date

Qualification Details

Select Examination

Select College

Select University

Enter Passing Year

Enter PRN No

Amount For this Application

Total Amount

Processing Amount

Documents Upload

Sr No.	Doc Name	File Type	*	File Size
1	Passport size Photograph (2cm width and 2.5cm Height )	.jpg	YES	50 kb
2	Candidate Sign (2.65cm width and 1.40cm Height)	.jpg	YES	50 kb
3	Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one)	.pdf	YES	150 kb
4	Marklist for the qualifying examination	.pdf	YES	150 kb
5	Certificate of passing the qualifying examination/Online Markssheet	.pdf	YES	150 kb
6	Internship doing Letter	.pdf	YES	150 kb
7	Bonafide certificate	.pdf	YES	150 kb
8	NOC from relieving Collge/Hospital	.pdf	YES	150 kb
9	NOC from relieving university/competent authority	.pdf	YES	150 kb
10	NOC from Receiving Collge/Hospital	.pdf	YES	150 kb
11	NOC from Receiving university/competent authority	.pdf	YES	150 kb
12	N.O.C from state council in original for other state candidate (If registered with other state council	.pdf	YES	150 kb

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