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.: MMC201808909
Registration No. : 2014062967 Regn Date : 23/06/2014
Appointment Date : 26/02/2018 Appointment time : Fisrt Half ( 10 Am - 1 Pm )

  Prefix Sur Name First Name Middle Name

Full Name : Mr. SHETH DEVANSH SUBHASHCHANDRA

Address as Per MMC Record : 402, RATNAKAR FLAT, OPP. AMRAPALI-3, JUDGES BUNGLOW ROAD, BODAKDEV, AHMEDABAD .,AHMEDABAD

Pin : 380015 Email : 11devansh@gmail.com

Tel No.(Reg.) : 079-26871331 Clinic :

Mobile No. : 8401622021      

Date of Renewal of Registration :

Additional Qulifications
: Dip. (Obst. & Gynae.)
(Name P.G. Degree/Diploma)
Name of collage from where you have
passed/acquired P.G.Qulification with proof
: C.P.S. MUMBAI
i.e. bonafide certificate from Head of
institute/dept
Name of University : C.P.S. MUMBAI

Year of Passing : 2016

  Enclosed:- Following certificate are to be attached with Application .

1. Passing Certificate of Diploma/Degree issued by University

2. Bonafide Certificate issued by the head of institute / head of department.
3. Marksheet of Diploma/Degree issued by University

Date:

Place: (Signature of the Applicant & Name)

This is to certify that Dr. _____________________________________________________________________________________________

MMC Registration No. _______________________________________ was enrolled for ___________________________________________

from  ______________________________________ to _______________________________ and satisfactory completed the same.

It has been verified from our record.

 Secretary
Head Of Concerned Training Institute
College Of Physician and Surgeon