International credentials services



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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


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.





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.

Visit the EICS website at www.ecfmg.org/eics for information on EICS and the EICS application



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.



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.


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.


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.

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 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.



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 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)

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 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.

_________________________________________________


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.


Signature Date of signature

_________________________________________________

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

_________________________________________________

Date of birth (day, month, year)

ECFMG Document Checklist




  1. Copies of documents submitted directly to ECFMG by applicant :

  • Academic transcripts – translations into English if in any other language




  • Degree certificates - translations into English if in any other language




  • Medical licence/registration certificate(s) - translations into English if in any other language




  • Photographs (signed at back)




  • Payment 




  • Signed affidavit




  • Authorization release





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