(For CPS Diploma Holders Only)

Name of college form where you have passed / acquired Diploma

9. Demand Draft of Rs.

This is to certified that Dr.__________________________________________________________________________________

MMC Registration No.__________________________ was enrolled for_____________________________________________

from________________________________ to___________________________ and satisfactorily completed the same.

It has been verified from our record.

Secretary

College of Physician and Surgeon

To,The 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 :

1. Full Name : ..................................................................................................................................

..................................................................................................................................

Tel. No. (Res.) ............................ Clinic ......................... Mobile No. .......................

2. Permanent Address : ..................................................................................................................................

..................................................................................................................................

......................................................................... Pin ..................................................

E-mail .......................................................................................................................

4. Permanent Registration Number : Regn. No. ............................................. Regn. Date .................................................with M.M.C.

5. Date of Renewal of Registration : ..................................................................................................................................

6. Additional Qualifications : ..................................................................................................................................

(Name of Diploma) ..................................................................................................................................

7. : ..................................................................................................................................

..................................................................................................................................

8. Year of Passing : ..................................................................................................................................

..................................................................................................................................

: ..................................................................................................................................

10. Demand Draft No. & Date : ..................................................................................................................................

11. Name of the Nationalised Bank & Place : ..................................................................................................................................

Enclosed :1. Passing Certificate / Diploma of additional qualification issued by CPS. (Attested Photocopy from CPS & original for verification)2. M.M.C. Registration Certificate & Photocopy of I-Card issued by MMC. Attested by gazetted officer.3. Demand Draft of Nationalised Bank in Favouring The Registrar, Maharashtra Medical Council Payable at Mumbai.4. If you have change your name please attached a xerox copy of M.M.C. letter.5. Two copies of latest photographs of passport size.

Date :

Place : (Signature of Applicant)

Application for Additional Qualification Registration with theMaharashtra Medical Council, Mumbai

RECENT

PHOTO

(PASSPORT SIZE)

Yours,

Head of Concerned Training Institute

6. Bonafide certificate issued by Head of Institute in Original & Attested copy.

MAHARASHTRA MEDICAL COUNCILWebsite : www.maharashtramedicalcouncil.in

Instructions for filling up the Application form for Additional Qualification Registration for CPS Diploma Holders

INSTRUCTIONS

1) Application needs to be filled in by the applicant.

2) All the particulars should be filled in block letters. No short forms should be used.

3) The applicant must ensure that the name entered in the application form exactly corresponds to his / her name with supporting documents.

4) An incomplete form or the one not accompanied by valid documents will not be accepted. No correspondence in this regard will be entertained.

5) Application alongwith all the required document as mentioned in the application form, may be submitted in person or sent by registered post / courier to the Registrar on the address mentioned in the application form.

6) Registration fee of Rs. 120/- (Rs. One Hundred Twenty Only) for each Additional Qualification.

8) Certificate will be issued within 30 working days from the date of payment receipt.

9) In case of change of address please see Maharashtra Medical Council Website. (www.maharashtramedicalcouncil.in)