International credentials services licensing authority : medical and dental professions board
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| EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG
INTERNATIONAL CREDENTIALS SERVICES LICENSING AUTHORITY : MEDICAL AND DENTAL PROFESSIONS BOARD HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA
Application for Verification of Credentials
1. Name
Enter your complete name and any maiden/alternate name.
Last Name (Surname) and Generational Suffix
__________________________________________________________________ First and Middle Name(s)
__________________________________________________________________ Maiden/Alternate Name(s) 2. Contact Information
Enter your mailing address, telephone and fax numbers and email address.
__________________________________________________________________ Street Address/Post Office Box
__________________________________________________________________ Address Continued
_______________________________ _________________________________ City State/Province
_______________________________ _________________________________ Country Postal/Zip Code
_______________________________ _________________________________ Telephone Number Fax Number
__________________________________________________________________ Email Address (Please type or print clearly) 3. Identification Number(s)
Enter the Medical and Dental Professions Board, USMLE/ ECFMG, and EICS identification numbers, if assigned.
__________________________________________________________________ Medical and Dental Professions Board Identification Number
__________________________________________________________________ USMLE/ECFMG Identification Number
__________________________________________________________________ EICS Identification Number (if previously assigned) 4. Date and Place of Birth
(Enter your date and place of birth.)
_______________________ ____________________ ___________________ Day Month Year
__________________________________ _____________________________ City State/Province
__________________________________________________________________ Country
EICS Identification No.
Check if you have previously applied to EICS. Complete application. Include EICS identification number in Item 3. See Instructions for Documentation (Item 8) and Fee (Item 9) information. Visit the EICS website at www.ecfmg.org/eics for information on EICS and the EICS application EICS – HPCSA 2
School(s)
List all medical schools attended outside of South Africa, not just the one from which you graduated.
If you attended more than two medical schools, photocopy this page to list the additional medical schools.
legible copies of your medical diploma and medical school transcript. If the documents are not in English, you must include official English translations.
See Items 5 and 8 of attached instructions.
Medical School of Graduation:
__________________________________________________________________ Full Name of Medical School
__________________________________________________________________ Street Address/Post Office Box
__________________________________________________________________ Address Continued
_______________________________ _________________________________ City State/Province
Country Postal/Zip Code _______________________________ _________________________________ Telephone Number Fax Number
Attended From ________________ to _______________________________ Month/Year Month/Year
______________________________ ________________________________ Graduation Date (Month/Year) Medical Degree Date (Month/Year)
Other medical school(s) attended:
__________________________________________________________________ Full Name of Medical School
__________________________________________________________________ Street Address/Post Office Box
__________________________________________________________________ Address Continued
_______________________________ __________________________________ City State/Province
_ Country Postal/Zip Code _______________________________ __________________________________ Telephone Number Fax Number
Attended From _________________ to _________________________________ Month/Year Month/Year
If additional sheet(s) listing other medical schools attended are enclosed, please check:
Additional sheet(s) enclosed.
EICS – HPCSA 3
Medical Education
List all postgraduate medical education obtained after graduation from medical school,
internships, residencies and fellowships.
If your postgraduate medical education was at more than two institutions, photocopy this page to list the additional institutions.
legible copies of the certificates confirming your postgraduate medical education. If the documents are not in English, you must include official English translations.
See Items 6 and 8 of attached instructions.
Most Recent Postgraduate Medical Education:
_________________________________________________________________ Full Name of Institution
_________________________________________________________________ Street Address/Post Office Box
Address Continued
_______________________________ _________________________________ City State/Province
____________________________ ______________________________
_______________________________ _________________________________ Telephone Number Fax Number
Attended From __________________ to ______________________________ Month/Year Month/Year
Specialty __________________________________________________________ Position Held (check one):
Intern Resident Registrar Fellow
__________________________________________________________________ Full Name of Institution
__________________________________________________________________ Street Address/Post Office Box
__________________________________________________________________ Address Continued
_______________________________ _________________________________ City State/Province
_______________________________ _________________________________ Country Postal/Zip Code
_______________________________ _________________________________ Telephone Number Fax Number
Attended From __________________ to _______________________________ Month/Year Month/Year
Specialty __________________________________________________________ Position Held (check one):
Intern Resident Registrar Fellow
If additional sheet(s) listing other institutions are enclosed, please check:
Additional sheet(s) enclosed.
EICS – HPCSA 4
License/ Registration
List all jurisdictions where a license to practice medicine was obtained outside of South Africa. Include permanent, limited and other special purpose license or registration.
documents are not in English, you must include official English translations.
See Items 7 and 8 of attached instructions.
is continued on page 5 Licensing/Registration Jurisdiction:
__________________________________________________________________ Full Name of Licensing/Registration Jurisdiction
__________________________________________________________________ License/Registration Number
Street Address/Post Office Box
Address Continued
_______________________________ _________________________________ City State/Province
___________________________ _ ______________________________
_______________________________ _________________________________ Telephone Number Fax Number
_______________________________ _________________________________ License Issue Date (Month/Year) License Expiration Date (Month/Year)
License/Registration Status (check one) Active
Inactive Suspended Revoked
If suspended or revoked, attach a separate sheet of paper and explain the reason.
__________________________________________________________________ Full Name of Licensing/Registration Jurisdiction
__________________________________________________________________ License/Registration Number
Street Address/Post Office Box
Address Continued
_______________________________ _________________________________ City State/Province
___________________________ _ ______________________________
_______________________________ _________________________________ Telephone Number Fax Number
_______________________________ _________________________________ License Issue Date (Month/Year) License Expiration Date (Month/Year)
If additional sheet(s) listing other jurisdictions are enclosed, please check:
EICS – HPCSA 5 7. Medical License/ Registration
Continued from page 4
License/Registration Status (check one) Active
Inactive Suspended Revoked
If suspended or revoked, attach a separate sheet of paper and explain the reason .
8. Documentation
Include two (2) complete and legible copies of all the documents listed here.
Documents not in English must include English translations. See instructions for English translation requirements.
Medical diploma Check if included
Medical school transcript Check if included
Medical license(s)/registration(s) obtained from jurisdictions outside South Africa Check if included
Postgraduate training certificates Check if included
Additional photographs that you have signed on the back Check if included
NOTE: Refer to instructions to arrange for verification shipment via courier service
9. Fees and Payment
Include money order or credit card information.
Applications lacking payment or payment information will not be processed
Fees for verification to: Medical and Dental Professions Board EICS verification of medical diploma, medical school transcript, medical license(s) and postgraduate training US$150.00
I have previously applied to EICS. My application fee is US$50.00
Money Order made payable to "EICS" enclosed: US$150.00 US$50.00 Or Credit Card to be charged: US$150.00 US$50.00
Check Card: Visa Master Card Discover
Credit Card Number: _________________________________________________
Expiration Date: Month _________________ Year _________________________ Address of Card Holder: _______________________________________________
_______________________________________________ City / State / Country: _______________________________________________
Name of Card Holder: _________________________________________________ Signature of Card Holder: ______________________________________________
EICS Identification No.
EICS – HPCSA 6 AFFIDAVIT AND RELEASE
I, the undersigned, hereby certify under oath that I am the person named in this application, that all statements I have or shall make on or in connection with the application are true, that I am the person named in the various forms and credentials furnished or to be furnished with respect to my application and that all documents, forms or copies I furnish with my application are true and correct.
I acknowledge that I have read and understand t he “Instructions for Completing the EICS Application” and have answered all questions contained in the application truthfully and completely.
copies of documents or records.
services, its employees, agents or representatives and any person furnishing information, records or documents of any and all liability. I authorize the ECFMG International Credentials Services to release information, material, documents, orders or the like relating to me or this application to the Medical and Dental Professions Board, Health Professions Council of South Africa at my request.
_________________________________________ Applicant’s Signature (must be signed in the presence of
a notary public, consular official or first class magistrate) _________________________________________________ Applicant’s printed last name, first name, middle initial,
suffix (e.g., Jr.) _________________________________________________ Date of signature (must correspond to date of notarization)
I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this individual by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the individual and with the photograph affixed hereto, and (b) comparing the individual’s signature made in my presence on this form with the signature on his/her identifying document. The statements in this document are subscribed and sworn before me by the individual on this _________ day, in the month of _______________, in the year _________.
X ________________________________________________________________________ Signature of Consular Official, First Class Magistrate, Notary Public (in Latin characters with English translations, where applicable.) _____________________________________________________________ Official Title Attach one current, full- face photo here. Use tape or glue: no staples, please.
EICS – HPCSA 7
AUTHORIZATION FOR RELEASE OF INFORMATION, DOCUMENTS AND RECORDS
I, the undersigned, hereby authorize the Educational Commission for Foreign Medical Graduates (ECFMG ) International Credentials Services (EICS) to collect, verify and maintain information and copies of documents and records for medical registration boards to which I am applying for licensure.
I request and authorize every person, medical school, university, institution, professional licensing board, hospital, clinic, government agency or other third parties and organizations and their representatives, to release information, records, diplomas, transcripts and other documents, concerning my professional education, qualifications, experience and competence, ethics, character and other information pertaining to me to the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Services (EICS).
I further request and authorize that the requested information, records, diplomas, transcripts and other documents be sent directly to:
ECFMG International Credentials services (EICS)
4 th Floor
3624 Market Street
Philadelphia, PA 19104 USA
Immunity and Release
I hereby extend absolute immunity to, and release, discharge and hold harmless from any and all liability: 1) the Educational Commission for Foreign Medical Graduates (ECFMG), 2) the ECFMG International Credentials Services (EICS), its employees, agents, representatives, directors and officers; 3) other agencies, medical schools, universities, institutions, hospitals and clinics providing information, their employees, representatives, directors and officers; and 4) any third parties and organizations for any acts, communications, reports, records, diplomas, transcripts, statements, documents, recommendations or disclosures involving me, made in good faith and without malice, requested and received by the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Services. I understand that EICS will not accept such information, records or documents forwarded by me.
_________________________________________________ Signature Date of signature
_________________________________________________ Printed last name, first name, middle initial, suffix (e.g., Jr.)
Date of birth (day, month, year)
Attach one current, full- face photo here. Use tape or glue; no staples or paper clips, please. Sign across the bottom or top of the photo. Do not sign back. Yüklə 104,23 Kb. Dostları ilə paylaş:
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