Application for Additional Qualification Registration with the
Maharashtra Medical Council, Mumbai
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 additional qualification under the Maharashtra Medical Council Act., 1965 and further to issue certificate of additional qualification to me. My particulars are as follows :
Application No.: MMC20230048517 Application Date : 25/07/2023  
Registration No. : 2019041507 Reg Date : 12/04/2019
Appointment Date : Appointment time :
  Prefix Sur Name First Name Middle Name
Full Name : Ms. SHAH ADITI VIKAS
Address as Per MMC Record : C/O SHAH HOSPITAL, LALPURI ROAD, WALCHANDNAGAR, TAL- INDAPUR, DIST- PUNE ,INDAPUR
Pin : 413114 Email : shahaditi2803@gmail.com
Tel No.(Reg.) : Clinic :
Mobile No. : 8275637800      
Date of Renewal of Registration : 23/04/2024
Additional Qulifications
(Name P.G. Degree/Diploma)		 : M.D.(Radio Diagnosis)
Name of college from where you have passed/acquired P.G.Qulification with proof i.e. bonafide certificate from Head of institute/dept : BOMBAY HOSPITAL INSTITUTE OF MEDICAL SCIENCES,MUMBAI
Name of University : MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
Year of Passing : 2023
Obtain the Certificate through : Speed Post

  Enclosed:- Following certificate are to be attached with Application .
1.Passport Size photograph
2.Passing Certificate of Diploma/Degree issued by University
3.Bonafide Certificate issued by the head of institute / head of department.
Date:
Place: (Signature of the Applicant & Name)



______________________________ FOR OFFICE USE ONLY ______________________________

CHECKLIST for submission of documents

1.Passing Certificate of Diploma/Degree issued by University Yes No
2.Bonafide Certificate issued by the head of institute / head of department. Yes No
3.Copy of MCI Scheduled/ Copy of Government notification Yes No
4.Marksheet of Diploma/Degree issued by University Yes No
5.Latest Passport Size Photograph Yes No
6.Registration Copy of Additional Qualification Yes No
7.NOC From Respective Council Yes No
8.Good Standing Certificate Yes No
  
Provisional Verification Final Verification
Name Name
Signature


 Signature
Date Date