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