FORM 186 - CERTIFICATION OF IDENTIFICATION FORM - NOTARY PUBLIC AND MEDICAL SCHOOL OFFICIAL
PART A. TO BE COMPLETED IN THE PRESENCE OF A CONSULAR OFFICIAL, FIRST CLASS
MAGISTRATE, NOTARY PUBLIC OR COMMISSIONER OF OATHS
USMLE®/ECFMG® ID Number:
Reference Code:
Name:
Date of Birth:
Medical School:
Attendance Dates:
Graduation Date:
Degree Date:
Certifying official must sign below
When completed and submitted to ECFMG, this Certification of Identification Form (Form 186) will become part of your ECFMG record and will be used to identify you when you
submit an application to ECFMG for a USMLE Step or Step Component within five years from the date this form is evaluated and accepted by ECFMG.
Sign this Form 186 in the presence of a Consular Official, First Class Magistrate, Notary Public, or Commissioner of Oaths. All information on an application and on the
Certification of Identification Form is subject to verification and acceptance by the Educational Commission for Foreign Medical Graduates.
I certify that I am the individual named above, am represented in the attached photograph(s), the photograph(s) were taken within 6 months of the date of this Certification of
Identification Form and that the signature below is my signature.
I request and authorize every person, medical school, university, hospital, government agency, or other entity to release information to ECFMG bearing on the content of my
application or any other document submitted to ECFMG including, but not limited to, records, diplomas, transcripts, and other documents concerning my identity, citizenship or
immigration status, educational, academic or professional history and status, or enrollment. I hereby authorize ECFMG to transmit any information in its possession, or that may
otherwise become available to ECFMG, bearing on the content of my application or any other document submitted to ECFMG, including, but not limited to, records, diplomas,
transcripts, and other documents concerning my identity, citizenship or immigration status, educational, academic or professional history and status, or enrollment, 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. For further information regarding ECFMG's data collection and privacy practices, please refer to our privacy policy available on the ECFMG website at
www.ecfmg.org/annc/privacy.html.
Signature of Applicant (in Latin Characters) X______________________________ Date: _______________ (day/month/year)
CERTIFICATION BY OFFICIAL 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 _____________.
X____________________________________________________________________________________________
Signature of Consular Official, First Class Magistrate, Notary Public, or Commissioner of Oaths (in Latin Characters)
________________________________________
Title (with English translation, if not in English)
PART B. TO BE COMPLETED BY MEDICAL SCHOOL OFFICIAL
I hereby certify that the photograph, signature and information entered in all parts of this form, including medical school, attendance dates, and graduation and degree dates,
accurately apply to the individual named above and that this individual is a graduate of the institution indicated below.
Signature of Medical School Official (in Latin Characters) X______________________________________________
(Signature must match exactly the signature on record with ECFMG)
Date: _______________ (day/month/year)
_______________________________________________________________________________________
Print Name (in Latin Characters with English translation, where applicable)
_______________________________________________________________________________________
Official Title (in Latin Characters with English translation, where applicable)
_______________________________________________________________________________________
Institution
THIS FORM MUST BE SENT TO ECFMG DIRECTLY FROM THE OFFICE OF THE MEDICAL SCHOOL OFFICIAL WHO
COMPLETES PART B.
Mail To: IWA ECFMG 3624 Market Street, 4th Floor, Philadelphia, PA 19104-2685 USA
Form 186 - Type C, Rev. Sep 2010
Yes. I have printed this Certif ication of Identif ication Form.
25/01/2011 ECFMG On-line Application
