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 

 

Office Use Only 

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 



 

 

5. Medical 



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. 

 

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. 

 

 




EICS 

 HPCSA 3 



 

 

6. Postgraduate 



Medical 

Education

 

 



List all postgraduate 

medical education 

obtained after 

graduation from 

medical school, 

outside of South 

Africa.  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. 

 



EICS 

 HPCSA 4 



 

 

7. Medical 



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. 

 

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. 



 


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: ______________________________________________ 

 

 

Office Use Only 



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.  

 

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 Services (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 



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. 

 

 

A photocopy or facsimile of this authorization shall be as valid as the original 

and shall be valid from the date signed. 

 

 

 



 

_________________________________________________ 

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. 

 

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