Licensing authority: medical and dental professional board health professions council of south africa



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EDUCATIONAL COMMISSION FOR

FOREIGN MEDICAL GRADUATES (ECFMG)

INTERNATIONAL CREDENTIALS SERVICE (EICS)

LICENSING AUTHORITY: MEDICAL AND DENTAL PROFESSIONAL BOARD

HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA

Application for Verification of Credentials

(Please refer to attached instructions)

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



3. Identification Number(s)

Enter the Medical and Dental Professional Board and USMLE/ECFMG Identification number(s), if assigned.



__________________________________________________________________

Medical and Dental Professional Board Identification Number (if assigned)

__________________________________________________________________

USMLE/ECFMG Identification Number (if assigned)

4. Date and Place of Birth

(Enter your date and place of birth.)


_______________________ ____________________ ___________________

Day Month Year
__________________________________ _____________________________

City State/Province


__________________________________________________________________

Country



Office Use Only


EICS Identification No.


5. Medical School(s)




List all medical schools attended, 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.

You must also include 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.




6. Postgraduate

Medical Education




List all postgraduate medical education, i.e, education taken after graduation from medical school. Include internships, residencies and fellowships. If your postgraduate medical education was at more than two institutions, photocopy this page to list the additional institutions.

You must also include 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


____________________________ ______________________________

Country Postal/Zip Code


_______________________________ _________________________________

Telephone Number Fax Number


Attended From __________________ to ______________________________

Month/Year Month/Year


Specialty __________________________________________________________
Position Held (check one):

 Intern  Resident  Registrar  Fellow


Other Postgraduate Medical Education:

__________________________________________________________________

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.



7. Medical License/

Registration




List all jurisdictions where a license to practice medicine was obtained. Include permanent, limited and other special purpose license or registration.




You must also include legible copies of your medical license/registration certificate(s). If the documents are not in English, you must include official English translations.


See Items 7 and 8 of attached instructions.

Note: Item 7


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


____________________________ ______________________________

Country Postal/Zip Code


_______________________________ _________________________________

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.
Other jurisdictions where a license/registration was obtained:
__________________________________________________________________

Full Name of Licensing/Registration Jurisdiction


__________________________________________________________________

License/Registration Number




Street Address/Post Office Box




Address Continued


_______________________________ _________________________________

City State/Province


____________________________ ______________________________

Country Postal/Zip Code


_______________________________ _________________________________

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:

 Additional sheet(s) enclosed.



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 legible copies of all the documents listed here. If documents are not in English, 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 



Four (4) additional photographs that you have signed on the back

Check if included 



9. Fees and Payment

Include money order or credit card information.



Fees for verification to: Medical and Dental Professional Board


EICS verification of medical diploma, medical school transcript,

medical license(s) and postgraduate training



$150.00
Money Order Enclosed  US $150.00 - made payable to “EICS”
or
Credit Card to be charged
Check Card: Visa  Master Card  Discover 
Credit Card Number:__________________________________________________
Expiration Date: Month _________________ Year _________________________
Address of Card Holder: _______________________________________________
_______________________________________________
Name of Card Holder: _______________________________________________
Signature of Card Holder:______________________________________________


Office Use Only


EICS Identification No.

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 the “Instructions for Completing the EICS Application” and have answered all questions contained in the application truthfully and completely.
I authorize every person, medical school, university, hospital, clinic, government agency or institution having custody or control of any documents, records and other information pertaining to me to furnish to the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Service (EICS) any such information, or true and correct copies of documents or records.
I hereby release, discharge and hold harmless ECFMG, the ECFMG International Credentials Service, its employees, agents or representatives and any person furnishing information, records or documents of any and all liability. I authorize the ECFMG International Credentials Verification Service to release information, material, documents, orders or the like relating to me or this application to the Medical and Dental Professional Board at my request.

Attach one current, full-face photo here. Use tape or glue: no staples, please.

_________________________________________

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



AUTHORIZATION FOR RELEASE OF

INFORMATION, DOCUMENTS AND RECORDS

I, the undersigned, hereby authorize the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Service (EICS) to collect, verify and maintain information and copies of documents and records for licensing jurisdictions 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 Service (EICS).
I further request and authorize that the requested information, records, diplomas, transcripts and other documents be sent directly to:
ECFMG International Credentials Service (EICS)

P.O. Box 13795

Philadelphia, PA 19101-3795

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 Service (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 Service. I understand that EICS will not accept such information, records or documents forwarded by me.





A photocopy or facsimile of this authorization shall be as valid as the original and shall be valid from the date signed.


_________________________________________________


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 the back.

Signature Date of signature

_________________________________________________

Printed last name, first name, middle initial, suffix (e.g., Jr.)

_________________________________________________

Date of birth (day, month, year)


THE EDUCATIONAL COMMISSION

FOR FOREIGN MEDICAL GRADUATES (ECFMG)



INTERNATIONAL CREDENTIALS SERVICE (EICS)

The Medical and Dental Professional Board of the Health Professions Council of South Africa requires that physicians seeking medical licensure/registration who completed their medical education outside South Africa submit copies of certain documents to the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Service (EICS). EICS will obtain primary source verification of the authenticity of these documents from the entity that issued these documents to you. The Medical and Dental Professional Board requires that you submit copies of the following documents to EICS for verification:




  • Medical school diploma;

  • Medical school transcript;

  • Medical licensure/registration certificates in other jurisdictions;

  • Postgraduate training certificates

Please complete the enclosed EICS Application for Verification of Credentials and send it to EICS with the required documents, four additional photographs and payment of $ US150.00. Instructions for completing the application are included.


After EICS receives your completed application, credentials and fee, EICS will secure primary source verification of the medical credentials. EICS will write to the institutions that issued the credentials: the medical school, licensing jurisdiction and program providing graduate medical education. EICS will send the institutions a copy of the document to be verified, a confirmation form to be completed and a photograph signed by you to assist in identification. EICS will ask the institution official to complete the confirmation form to verify the credentials and return the confirmation form directly to EICS.
If EICS does not receive verification of a document within sixty (60) days of our request, EICS will notify you and the Medical and Dental Professional Board regarding the documents that have not yet been verified. EICS will make a second request for verification of these documents. If EICS does not receive the confirmation form for a document within four (4) months of the initial request, EICS will notify you and the Medical and Dental Professional Board regarding any documents we have been unable to verify.
After verification of all the required credentials has been secured, an EICS report will be sent to the Medical and Dental Professional Board. The report will contain your name and biographic information and a list of the medical credentials that were verified. The EICS report will also include copies of the credentials that were verified.
The EICS application packet consists of the following items:


  • Instructions for Completing the ECFMG International Credentials Service (EICS) Application

  • ECFMG International Credentials Service (EICS) Application

  • Affidavit and Release

  • Authorization for Release of Information, Documents and Records

INSTRUCTIONS FOR COMPLETING THE EDUCATIONAL COMMISSION

FOR FOREIGN MEDICAL GRADUATES (ECFMG)

INTERNATIONAL CREDENTIALS SERVICE (EICS) APPLICATION
Please read these instructions carefully before completing the application for verification of credentials. Please type or print neatly in ink the information requested on the application. If you fail to submit all required information and documentation, processing of your application by the Educational Commission for Foreign Medical Graduates (ECFMG) International Credentials Service (EICS) shall be delayed.

INSTRUCTIONS




Item 1 “Name


Enter your full name. Your last name (surname) and generational suffix must be on line 1. Your first and middle name(s) must be on line 2. Your maiden/alternate name(s) must be on line 3.

Item 2 “Contact Information”


Enter your complete mailing address. This is the address that EICS will use in communicating with you in writing. Also include your telephone and fax numbers. If you have an email address, also include that address.

Item 3 “Identification Number”


If the Medical and Dental Professional Board has assigned you an identification number, please list that number. If you have a USMLE/ECFMG Identification Number, include that number as well.

Item 4 “Date and Place of Birth”


Enter your date of birth in the following order: 1) day, 2) month and 3) year. Also include the city, state/province and country where you were born.
Item 5 “Medical School(s)”

Enter the full names, addresses and attendance dates for all the medical schools you attended. List the medical school from which you graduated first, then the other medical schools you attended, if applicable. You must list your graduation and medical degree dates for the medical school from which you graduated and the attendance dates for all the medical schools you attended. Include the telephone and fax numbers of the medical schools, if available.


If you attended more than two medical schools, photocopy that page of the EICS application and use the photocopied page(s) as an attachment to the EICS application. Check the box on the application to indicate an additional sheet is attached.
Item 6 “Postgraduate Medical Education”

Enter the full names, addresses and attendance dates for all the institutions where you obtained postgraduate medical education, i.e., education taken after graduation from medical school. This includes all internships, residencies and fellowships. The specialty must be listed as well. Include telephone and fax numbers of the programs, if available.


If you obtained postgraduate medical education at more than two institutions, photocopy that page of the EICS application and use the photocopied page(s) as an attachment to the EICS application. Check the box on the application to indicate an additional sheet is attached.

Item 7 “Medical License/Registration”


Enter the full names, addresses and licensure/registration dates for all the medical license/registration jurisdictions where you obtained a license/registration to practice medicine. Include permanent, limited and other special purpose licenses or registration. Include the telephone and fax numbers of the license/registration jurisdictions, if available. You must also check the appropriate box to indicate the current status of each license/registration. If the license/registration was suspended or revoked, you must attach a separate sheet of paper and explain the reason.
You must include a copy of the license/registration document from each jurisdiction in which you have ever been licensed/registered. Any document not in English must be accompanied by an official English translation (see Item 8 “Documentation” below.)
If you obtained a license/registration to practice medicine in more than two licensing/registration jurisdictions, photocopy that page of the EICS application and use the photocopied page(s) as an attachment to the EICS application. Check the box on the application to indicate an additional sheet is attached.

Item 8 “Documentation”


The documents required by the Medical and Dental Professional Board are listed below. Include legible copies of all these documents:


  • Medical Diploma

  • Medical School Transcript

  • Postgraduate Medical Education Certificate(s)

  • Medical License/Registration Certificate(s)

Any document not in English must be accompanied by an official English translation. The English translation must be prepared by and certified to be correct by a government official, medical school official or translation service that is acceptable to EICS. The translation must appear on official stationery, must identify the translator and must bear the signature of the official or representative of the translation service.


You must also include four (4) additional passport size photographs. Sign your name on the back of each photograph. These are in addition to the photographs on the Affidavit and Authorization forms. You will need to submit a total of six (6) photographs.

Item 9 “Fees and Payment”


The EICS fee for verification of the medical diploma, medical school transcript, postgraduate training certificate(s) and medical license/registration is US $150.00
Include the payment information: whether a money order for US $150.00 is enclosed or if the fee should be charged to a credit card. For a credit card payment, you must indicate the type of card (Visa or MasterCard), credit card number, expiration date and the address, name and signature of the cardholder.
Affidavit and Release

Complete the Affidavit and Release by signing your name on the first line, printing your name on the second line and dating your signature on the third line. Attach one current, full-face photograph of yourself in the designated box. Have the Affidavit and Release certified by a notary public, first-class magistrate or consular official. Be sure the official dates and signs the document and lists his or her official title.


Authorization for Release of Information, Documents and Records

Complete the Authorization by signing your name and dating your signature on the first line, printing your name on the second line and listing your date of birth on the third line. Attach one current, full-face photograph of yourself in the designated box and then sign your name across the front of the photograph.






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