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.: MMC20230062906 Application Date : 06/10/2023  
Registration No. : 2023106951 Reg Date : 05/10/2023
Appointment Date : Appointment time :
  Prefix Sur Name First Name Middle Name
Full Name : Ms. ASHWATI KRISHNAN RAJIV
Address as Per MMC Record : NIRANJANA, FLORICAN HILL ROAD KARAPARAMBU PO KOSHIKODE, KERALA - PIN 673010 ,CALICUT
Pin : 673010 Email : ashwati.189@gmail.com
Tel No.(Reg.) : 34-1435 Clinic :
Mobile No. : 9633177282      
Date of Renewal of Registration :
Additional Qulifications
(Name P.G. Degree/Diploma)		 : M.S.(Genl. Surg.)
Name of college from where you have passed/acquired P.G.Qulification with proof i.e. bonafide certificate from Head of institute/dept : AFMC PUNE
Name of University : MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
Year of Passing : 2022
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