To,
Registrar ,
Maharashtra Paramedical Council ,
Gate No.02, Cama & Albless Hospital
1st Floor, New Admin Building
Mahapalika Marg, Dhobi Talao, CSMT, Fort
Mumbai - 400001 , Maharashtra.
Sir,
Please verify the authenticity of the documents and allow me to register my name for the course of --------------------------------------------------------------------.The receipt of Registration fees of Rs.5000/- is enclosed herewith.

Application No : 202306113

Application Date : 15/10/2023

Personal Details:

		Prefix	Surname	First Name	Middle Name
Name of Applicant	:	Mr.	BEMBALE	SHAHADEV	DATTATRAY
Name of Applicant(In Devnagari)	:		बेंबळे	शहादेव	दत्तात्रय
Name of Father	:	Mr.	BEMBALE	DATTATRAY	GANGADHAR
Name of Mother	:	Mrs.	BEMBALE	INDUBAI	DATTATRAY
Name of Mother (In Devnagari)	:		बेंबळे	इंदुबाई	दत्तात्रय
	In Case of Married Women
Maiden Name	:
Date of Birth	:	01/06/1978	Aadhaar No	565713629775
Gender	:	Male	Marrital Status	MARRIED
Nationality	:	INDIAN

Contact Details:

Permanent Address as Per Aadhaar Card
Address	:	AT-DEOSADE,POST-KUKANA
City/Taluka	:	NEWASA	District	:	AHMEDNAGAR
State	:	MAHARASHTRA	Pincode	:	414604
Place of Practice with full address
Address	:	AT POST-KUKANA,OMKAR CLINICAL LABORATORY
City/Taluka	:	NEWASA	District	:	AHMEDNAGAR
State	:	MAHARASHTRA	Pincode	:	414604
Mobile No	:	8975071476	Email Id	:	shahadevbembale029@gmail.com
Residential No	:		Clinic No	:

Qualification Details:

Sr.No.	Education Qualification	Subject	Name of University/Exam board	Name Of Institute	Institute Address	Roll no/Seat no	Year Of Passing	University Enrollment No.	Internship Period	Name & address of Institution from where Internship completed
1	S.S.C		MAHARASHTRA STATE BOARD	KUKANE ENGLISH SCHOOL	KUKANE,TALUKA-NEWASA,DIST-AHMEDNAGAR	C121304	1995		-
2	H.S.C		MAHARASHTRA STATE BOARD	KUKANE MADHYAMIK VHA UCCHA MADHYAMIK VIDHYALAYA	KUKANE,TALUKA-NEWASA,DIST-AHMEDNAGAR	C047032	1998		-
3	Diploma	Medical Laboratory Technology	Maharashtra State Board of Technical Education		AT POST-DAREWADI,TAL & DIST-AHMEDNAGAR	458352	2023	2120510005	-
4	Degree BPMT/BSC in Paramedical				KADA,TAL-ASHTI,DIST-BEED	CP127000004	0	2016017000037847	-
5	Plain BSC						0		-
6	Certificate/MCVC Certificate						0		-

Ceritificate Verification detail

Appl No	:	202303719	Appl Date	:	18/07/2023
Amount	:	2000.00	Transaction Date	:	18/07/2023
ATRN No.	:	9616076252913	Bank ref No.	:	319913840130

Appl No	:	202306113	Appl Date	:	15/10/2023
Amount	:	5000.00	Transaction Date	:	15/10/2023
ATRN No.	:	9825614320228	Bank ref No.	:	328883432082

continued on next page

I forwarded herewith the following documents :
1.	Print out of submitted Registration form with signature
2.	Two Copies of Online Payment Receipt of Registration Fees of Rs. 5000/- (Rupees Five Thousand Only).
3.	Original Degree Cetificate/Diploma Certificate of paramedical qualification .
4.	Original Marksheet of paramedical Degree/Diploma of I/II/III/Iv year which is applicable.
5.	Original Marksheet of S.S.C & H.S.C. Markssheet & Certificate
6.	Three Copies of recent color passport size photograph (3*4 CM)