Applicant Photo and Seal Name: Elena Alexandrovna Bulakhtina
Application ID Code: 8-683-126-916
Step 1 Eligibility Period: Oct 2003 to Dec 2003

Status of Medical Diploma:
I have graduated from medical school and will submit, with my Certification Statement (Form 183), one photocopy of my medical diploma to ECFMG.

Students and graduates must sign this Certification Statement in the presence of their Medical School Dean, Vice Dean or Registrar. If a graduate cannot sign this Certification Statement in the presence of a medical school official noted above, he/she must sign the Certification Statement in the presence of a Consular Official, First Class Magistrate or Notary Public.
Certification Statements are to be mailed to ECFMG from the office of the official or notary who witnesses the applicant’s signature. All information on the Certification Statement is subject to verification and acceptance by the Educational Commission for Foreign Medical Graduates.

I hereby certify that I currently meet the examination eligibility requirements and that the information in my application and on this Certification Statement is true and accurate to the best of my knowledge and that the photographs enclosed were taken within 6 months of the date of this application.
For individuals applying for USMLE Step 1/Step 2: I also certify and acknowledge that I have read the appropriate edition (that which pertains to the eligibility period for which I am registering) of the ECFMG Information Booklet and USMLE Bulletin of Information, am aware of the contents of both publications, meet the eligibility requirements set therein and agree to abide by the policies and procedures therein.
For individuals applying for the CSA: I also certify and acknowledge that I have read the current edition (that which pertains to the administration for which I am registering) of the ECFMG Information Booklet, am aware of its contents, meet the eligibility requirements set therein and agree to abide by the policies and procedures therein.
I understand that (1) falsification of this application, or (2) the submission of any falsified documents to ECFMG, or (3) the submission of any falsified ECFMG documents to other agencies, or (4) the giving or receiving of aid in the examination as evidenced either by observation at the time of the examination or by statistical analysis of my answers and those of one or more other participants in that examination, or engaging in other conduct that subverts or attempts to subvert the examination process, may be sufficient cause for ECFMG to bar me from the examination, to terminate my participation in the examination, to withhold and/or invalidate the results of my examination, to withhold a certificate, to revoke a certificate, or to take other appropriate action. (See "Validity of Scores" and "Irregular Behavior" in the appropriate edition of the Information Booklet for additional details.)
I understand that the Standard ECFMG Certificate and any and all copies thereof remain the property of ECFMG and must be returned to ECFMG if ECFMG determines that the holder of the Certificate was not eligible to receive it or that it was otherwise issued in error.
I request and authorize every person, medical school, university, hospital, government agency, or other entity to release information, records, diplomas, transcripts and other documents concerning my professional education, academic status or enrollment to ECFMG upon request of ECFMG. I hereby authorize ECFMG to transmit any information contained in this application, or information that may otherwise become available to ECFMG, to any federal, state or local governmental department or agency, to any hospital or to any other organization or individual who, in the judgment of ECFMG, has a legitimate interest in such information.

Signature of Applicant (in Latin Characters) X________________________   Date: (day/month/year)


Certification by Identification:
I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this applicant by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph affixed hereto, and (b) by comparing the applicant'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 to before me by the applicant on this _________ day, of the month of _______________, in the year _____________.


Signature of Consular Official, First Class Magistrate, Notary Public (in Latin characters with English translations, where applicable)

______________________________________________________________ Official Title 

Form 183, Rev. Aug 2002