Application Number: RPR-15-19135(17/06/2015)

Note: 1. This form may be kept for future reference only.

APPLICATION TO ATOMIC ENERGY REGULATORY BOARD (AERB) FOR REGISTRATION OFRADIATION PROFESSIONAL

Application Number : RPR-15-19135Date of Application : 17/06/2015

Personal Details:Name : Dr. ROHIT MALDEDate Of Birth : 18/03/1976Practice : RadiotherapyProfessional Role : Radiation OncologistGender : MaleIdentification Type : PAN card issued by Income Tax Department Identification No. : AIAPM7331EAadhar No. :

Residential Address:Residential Address : D1002, NIHARIKA BLDG, KANAKIA SPACES OPP

LOKPURAM TEMPLE, GLADYS ALWARES ROAD Landmark : OFF POKHRAN RD NO 2State : MaharashtraCity/District : ThanePIN : 400610

Permanent Address:Permanent Address : D1002, NIHARIKA BLDG, KANAKIA SPACES OPP

LOKPURAM TEMPLE, GLADYS ALWARES ROAD. Landmark : OFF POKHRAN RD NO 2State : MaharashtraCity/District : ThanePIN : 400610

Contact Details:PhoneNo(R) : - MobileNo (Permanent) : 9619503824Email (Permanent) : rohitmalde@gmail.com

Basic Education Details:

Course Name Year Of Passing Institution Name Board/University Subjects

M.B.B.S 2000 Terna Medical College

University of Mumbai Medicine

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Application Number: RPR-15-19135(17/06/2015)

Professional Education Details:

Course Name Year Of Passing Institution Name Board/University Subjects

M.D. (Radiotherapy) 2003 Tata Memorial Hospital

University of Mumbai Radiotherapy

DNB (Radiotherapy) 2003 Tata Memorial Hospital

University of Mumbai Radiotherapy

FRCR (UK) 2011 Royal College of London

Royal College of Radiologists and Clinical Oncologists

Clinical Oncology

Internship/Experience Details:

Category Role Institution Name Start Date End Date

Internship Registrar Tata Memorial Hospital

04/03/2013 27/02/2015

Attachment Description File Name

Your Photograph Rohit.jpg

Proof of Identity and Date Of Birth pancard.jpg

M.B.B.S MBBS Certificate.jpg

M.D. (Radiotherapy) Education_1c_MD Radiotherapy.jpg

DNB (Radiotherapy) Education_1e_Certificate_DNB Radiotherapy.jpg

Internship sks letter.jpg

Others Education_1f_FRCR Certificate.jpg

I hereby undertake that all the particulars provided in the application are correct to the best of my knowledge and belief.

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