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Application for Provisional Registration with the
Maharashtra Medical Council, Mumbai
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 1st Floor, Sane Guruji Marg, Arthur
Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sir,
I Request you to register my name provisionally under section 25 of the Indian Medical Council
Act 1956 and issue the necessary certificate. My particulars are as follows:
Application No.: MMC20240046476 Application Date : 28/07/2024
Appointment Date : Appointment time :
Prefix Sur Name First Name Middle Name
Name of
: Ms. GAIKWAD VEDIKA VIKAS
Applicant
Name of
: Mr. GAIKWAD VIKAS VISHNU
Father
Name of
: Mrs. GAIKWAD BHAGYASHREE VIKAS
Mother
In Case of Married Women
Maiden
:
Name
Name of
:
Husband
Present Address For TOWER8/802 SHREE KRISHNA PARADISE [Link], SECTOR-
:
Communication 12,PLOTNO-D69, KHARGHAR,NAVI MUMBAI
City/Taluka : PANVEL District : RAIGAD
State : MAHARASHTRA Country : INDIA
Pincode : 410210 Nationality : INDIAN
Mobile No : 8419988321 Email Id : vedikavg2000@[Link]
Residential No : 8419988321 Clinic No :
Date of birth : 05/06/2000 :
Gender : F Marrital Status : S
Name of the VEDANTAA
qualifying : M.B.B.S. Name of the College : INSTITUTE OF
Examination MEDICAL SCIENCES
MAHARASHTRA Year of passing the
Name of the
: UNIVERSITY OF HEALTH qualifying : 2024
Univeristy
SCIENCES, NASHIK examination
Date of starting Date of Completion
: 03/07/2024 : 01/07/2025
Internship in Internship
I have enclosed following certified copies attested by Dean of Medical College from where he has
passed.
1. Passport size Photograph
2. Latest Signature
Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any
3.
one)
4. Marklist for the qualifying examination
5. Certificate of passing the qualifying examination/Online Markssheet
6. Internship Letter
7. Bonafide certificate
DECLARATION (Student)
I am applying for Provisional Registration for the first time and I was not registered as a medical
practitioner in India / Abroad before the date of this application. I am aware of the legal
consequences of misleading the Maharashtra Medical Council or violating the limitations on
practice in herewith provisional registration. I have carefully read the instructions and I certify
that the particulars furnished above are true to the best of my knoweledge and belief.
Date: :
Place : (Signature of the Applicant & Name)
Particulars Of Payment
Receipt No : 27057811 Receipt Date 29/07/2024
CERTIFICATION BY DEAN
Certified that the above information of the candidate is verified from the record of the College /
Institute and found to be Correct .The said Intern is Bonafide Student of this College and have
started his/her Internship from 03/07/2024
Place :
Date :
(Signature of Dean)
______________________________ FOR OFFICE USE ONLY ______________________________
CHECKLIST for submission of documents
1. Passport size Photograph Yes No
2. Latest Signature Yes No
3. Proof of date of birth(School leaving cert/Birth Certificate/SSC passing certificate/Passport any one) Yes No
4. Marklist for the qualifying examination Yes No
5. Certificate of passing the qualifying examination/Online Markssheet Yes No
6. Internship Letter Yes No
7. Bonafide certificate Yes No
Provisional Verification Final Verification
Name Name
Signature Signature
Date Date