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PRIMARY SOURCE VERIFICATION APPLICATION SPECIALIST IN TRAINING INTERNATIONAL MEDICAL GRADUATES FOR MEDICAL BOARD OF

PRIMARY SOURCE VERIFICATION APPLICATION SPECIALIST IN TRAINING

INTERNATIONAL MEDICAL GRADUATES FOR MEDICAL BOARD OF AUSTRALIA REGISTRATION PURPOSES

IMPORTANT INFORMATION

1. This form is not an application for specialist recognition, but for an international medical graduate in an approved specialist-in- training position, which requires only EICS verification for Medical Board of Australia registration purposes.

2. If you require specialist recognition, you need the Specialist Application (A) and Specialist Application (B) forms.

3. This application form is for verification of both primary and specialist qualifications.

4. Applications for verification received on Occupational Trainee forms will not be processed.

If your application is assessed as incomplete, you will have to pay an incomplete application fee (AUD110) and submit the outstanding documentation within six months from the date of initial assessment. If you do not provide the required documentation, your application will lapse and your documentation will be destroyed. When you require a new assessment, you will keep your AMC candidate number. You will be required to submit a new application by completing the relevant paper-based application including the full application fee and ALL required documentation. Forms incorrectly completed will not be assessed and will be returned to candidates. Candidates will forfeit the application fee, and another full application fee will then be required with the correctly completed application form and all required documentation as listed in the checklist.

The Medical Board of Australia has established a national policy for all international medical graduates and overseas trained specialists for the assessment of qualifications by the Educational Commission for Foreign Medical Graduates (ECFMG) via the Australian Medical Council (AMC). Incomplete or incorrect applications will not be processed and a fee of AUD110 will be applied. This form must be lodged with the fee of AUD230 with the AMC. The Specialist-in-Training application will not be accepted by email or facsimile.

PRIMARY SOURCE VERIFICATION APPLICATION SPECIALIST-IN-TRAINING INTERNATIONAL MEDICAL GRADUATES FOR MEDICAL BOARD OF

PRIMARY SOURCE VERIFICATION APPLICATION SPECIALIST-IN-TRAINING

INTERNATIONAL MEDICAL GRADUATES FOR MEDICAL BOARD OF AUSTRALIA PURPOSES.

IDENTITY OF APPLICANT

Family name

(Surname)

Given names

Date of birth

APPLICANT Family name (Surname) Given names Date of birth Day Month Year Male Female OFFICE USE
APPLICANT Family name (Surname) Given names Date of birth Day Month Year Male Female OFFICE USE
Day Month Year
Day
Month
Year

Male

(Surname) Given names Date of birth Day Month Year Male Female OFFICE USE ONLY FILE NUMBER

Female

Given names Date of birth Day Month Year Male Female OFFICE USE ONLY FILE NUMBER DATE
Given names Date of birth Day Month Year Male Female OFFICE USE ONLY FILE NUMBER DATE
OFFICE USE ONLY FILE NUMBER DATE RECEIVED STAMP Code: ………….………… Rcpt: ………………………
OFFICE USE ONLY
FILE NUMBER
DATE RECEIVED
STAMP
Code: ………….…………
Rcpt: ………………………
Amount: …………………
Prcd by: …………………
………………… Prcd by: ………………… Country of birth ADDRESS FOR CORRESPONDENCE Address
………………… Prcd by: ………………… Country of birth ADDRESS FOR CORRESPONDENCE Address

Country of birth

ADDRESS FOR CORRESPONDENCE

Address

State

Country

CONTACT DETAILS

Home phone

Mobile

Email address

CONTACT DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION
CONTACT DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION
CONTACT DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION

Postcode

DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION Country
DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION Country
DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION Country
DETAILS Home phone Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION Country

Work phone

Facsimile

Mobile Email address Postcode Work phone Facsimile PRIMARY MEDICAL QUALIFICATION Country of training Year

PRIMARY MEDICAL QUALIFICATION

Country of training Year qualified Primary qualification Year awarded Name on diploma Medical school Controlling
Country of training
Year qualified
Primary qualification
Year awarded
Name on diploma
Medical school
Controlling university

PRINCIPAL/HIGHEST SPECIALIST MEDICAL QUALIFICATION

(This qualification will be sent for EICS verification with your primary qualification)

Qualification obtained Year qualified Country of training Year awarded Institution awarding qualification (medical
Qualification obtained
Year qualified
Country of training
Year awarded
Institution awarding
qualification
(medical college)
Controlling university
SECONDARY/SUPPORTING SPECIALIST MEDICAL QUALIFICATION
Qualification obtained
Year qualified
Country of training
Year awarded
Institution awarding
qualification
(medical college)
Controlling university
ADDITIONAL SECONDARY/SUPPORTING SPECIALIST MEDICAL QUALIFICATION
Qualification obtained
Year qualified
Country of training
Year awarded
Institution awarding
qualification
(medical college)
Controlling university
NAME CHANGE/VARIATION
Is the name shown above the same as that shown on all the attached documents?
Yes
No (*read below)

* If NO, you are required to attach certified documentary evidence of your change of name. If submitting a statutory declaration, ensure that all variations are explained and state which name you wish to be known as for AMC purposes.

EVIDENCE OF IDENTITY

All applicants applying through the Australian Medical Council (AMC) must satisfy the AMC of their identity. Applicants will need to provide proof of personal identity by way of submission of two (2) types of identification documentation. To view these requirements, visit the AMC website (www.amc.org.au). Please note that meeting the AMC’s requirements for identification will not necessarily satisfy the Medical Board of Australia’s proof of identity requirements.

Tick this box if you have submitted certified evidence of identification

Tick this box if you have submitted certified evidence of identification Updated January 2012 Page 3

METHOD OF PAYMENT

METHOD OF PAYMENT I wish to have my primary and/or principal/highest specialist qualifications assessed, including EICS

I wish to have my primary and/or principal/highest specialist qualifications assessed, including EICS verification AUD230

Payment can be made by

Payment can be made by Bank cheque

Bank cheque

Payment can be made by Bank cheque

PLEASE PRINT CLEARLY

 

Credit card type

MasterCard

MasterCard

 
Credit card type MasterCard  

(Note: MasterCard/Visa debit cards are not accepted)

Money order (payable to Australian Medical Council)

Credit card (see below) (see below)

Visa

Note: Recording the expiry date will be taken as consent to record the credit card details and process payment.

Credit card number

Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  

Card expiry date

Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
Credit card number Card expiry date  
 
 

Month

Year

Cardholder’s signature

 

Date

Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date
Cardholder’s signature   Date

Day

Month

Year

 

Name of person to whom the AMC receipt is to be issued

Name of person to whom the AMC receipt is to be issued PAYMENT FOR ASSESSMENT IS

PAYMENT FOR ASSESSMENT IS REQUIRED EVEN IF EICS VERIFICATION HAS ALREADY BEEN CONFIRMED

EICS VERIFICATION

Since January 2006, all applicants for the AMC examination (for non-specialist registration) and the AMC specialist college assessment pathway (for registration as a specialist) require primary source verification of their medical qualifications through the International Credentials Services of the Educational Commission for Foreign Medical Graduates (ECFMG) in the United States of America.

Applicants will continue to apply to the AMC for initial assessment. Subject to the vetting of their documents by the AMC, applicants will be able to continue with the AMC examination or the specialist assessment. The documents will be forwarded to the ECFMG for verification through the original issuing university or institution. When confirmation of verification is received by the AMC, the candidature will be confirmed. The AMC will not be able to issue a final AMC Certificate after successful completion of the AMC examination process, until the verification has been confirmed.

Candidates who have previously obtained confirmed verification of their primary medical degree through the EICS will be required to provide the AMC with their EICS number and sign the Authorisation for Release of Information Form to enable the AMC to obtain a copy of the verification report from the EICS.

EICS NUMBER

a copy of the verification report from the EICS. EICS NUMBER USMLE NUMBER PRIVACY Your privacy

USMLE NUMBER

verification report from the EICS. EICS NUMBER USMLE NUMBER PRIVACY Your privacy is respected by the

PRIVACY

Your privacy is respected by the AMC. Information collected by the AMC may be used for administering the assessment of the Primary Source VerificationSpecialist-in-Training Application and provided to officers of the specialist colleges and the Medical Board of Australia.

The AMC privacy procedures are set out in a Privacy Policy statement which can be obtained from the AMC. If you have any privacy concerns or would like to verify information held about you, please contact the Privacy Officer, Australian Medical Council Limited, PO Box 4810, KINGSTON ACT 2604, Australia.

Consent to collect information

Signature

Council Limited, PO Box 4810, KINGSTON ACT 2604, Australia. Consent to collect information Signature Date Day

Date

Day Month Year
Day
Month
Year

DECLARATION BY APPLICANT

Please print clearly in sections below and complete all fields

I,

(Name)

of

(Address)

(Occupation)

DO SOLEMNY AND SINCERELY DECLARE THAT:

I am the person identified in the foregoing Specialist Application (A)

I am the person who has signed below

I have signed the Primary Source Verification of Medical QualificationsAuthorisation for Release of Information Form

I have familiarised myself with the AMC’s requirements, procedures and policies as set out in relevant AMC publications and on its website, as well as with its Privacy Policy

The statements made, and the information provided, in this application form and in the certified documents attached are true and complete.

Signature of person making the Declaration and Consent to Collect Information (applicant’s signature):

Please sign inside the box to ensure that the AMC is recording your full signature

box to ensure that the AMC is recording your full signature Declared at the day of

Declared at

the

Declared at the day of   year  

day of

 

year

 
 

Name of city, town, suburb

Date
Date
Month
Month
Year
Year

Before me*

 

(Witness)

Signature of person before whom the Declaration is made

Signature of person before whom the Declaration is made Insert official title** of witness before whom
Signature of person before whom the Declaration is made Insert official title** of witness before whom

Insert official title** of witness before whom the Declaration is made

Insert address of witness before whom the Declaration is made

address of witness before whom the Declaration is made Please print name of witness in BLOCK
address of witness before whom the Declaration is made Please print name of witness in BLOCK
address of witness before whom the Declaration is made Please print name of witness in BLOCK

Please print name of witness in BLOCK LETTERS

Contact number of witness.

* The person witnessing this Declaration must be the same person who certifies the documents of the applicant. If a different eligible witness is used the certify the supporting documentation you must submit a statutory declaration explaining why a different witness was used and it must be witnessed by the new eligible witness.

** The title of the witness must be written (e.g. Notary Public, Justice of the Peace).

PRIMARY SOURCE VERIFICATION OF MEDICAL QUALIFICATIONS Authorisation for Release of Information Form I hereby authorise:

PRIMARY SOURCE VERIFICATION OF MEDICAL QUALIFICATIONS

Authorisation for Release of Information Form

I hereby authorise:

1. The Australian Medical Council Limited (AMC) to submit my personal (identifying) information and my candidate Information (documents in support of my medical credentials) to the Educational Commission for Foreign Medical Graduates (ECFMG) for the purpose of verification and/or source verification in respect of my application.

2. ECFMG to retain such information in ECFMGs database for the purposes of

a) addressing any further requests from AMC for verification and/or source verification in respect of my application

b) responding to any request sent to ECFMG from an authority other than AMC, as authorised by me, or directly from me, to verify and/or source verify my credentials

c) internally accessing those portions of the data which are not personal information in order to verify credentials of other persons from time to time.

I request and authorise every person, institution, professional licensing board of any state or country in which I hold or may have held a license to practise my profession, hospital, clinic, government agency (local, state, federal or foreign), law enforcement agency or other third parties and organisations, and their representatives, to release information, records, transcripts and other documents, concerning my professional qualifications and competence, ethics, character and other information pertaining to me, to ECFMG.

I further request and authorise that the requested information, documents and records be sent directly to:

Educational Commission for Foreign Medical Graduates 3624 Market Street Philadelphia, PA 19104, U.S.A.

IMMUNITY AND RELEASE

I hereby extend absolute immunity to, and release, discharge and hold harmless from any and all liability:

a) ECFMG and AMC and their respective agents, representatives, directors and officers

b) other licensing boards, government agencies, institutions, hospitals and clinics providing information pursuant to this authorisation, and their representatives, directors and officers

c) any third parties and organisations for any acts, communications, reports, records, transcripts, statements, documents, recommendations or disclosures involving me, made in good faith and without malice, requested or received by ECFMG or AMC or any other third party.

By my signature below, I acknowledge that information, documents and records required to be furnished by another organisation, educational institution, hospital, individual or any person or groups of persons must be sent directly by such persons to ECFMG. I understand that ECFMG will not accept such information, records or documents forwarded by me.

A photocopy or facsimile of this authorisation form shall be as valid as the original and valid from the date signed.

be as valid as the original and valid from the date signed. Date of signature Day

Date of signature

Day Month Year
Day
Month
Year

Signature Ensure this signature is similar to the signature on the Application Declaration. Please sign inside the box to ensure the AMC is recording your full signature

PLEASE PRINT

Family name/Surname

First name

Middle initial, Suffix (e.g. Jr)

Date of birth Please ensure your date of birth is written in full (e.g 23 January 1970)

Securely glue in this square a current front- view passport-sized colour photograph of yourself in the block below.

Please clearly print your full names on the back of this photo.

The passport-sized photographs MUST be:

in colour good quality no older than 12 months no smaller than 35 mm x 45 mm no larger than 40 mm x50 mm no ink or marks on the edges not too dark not too light

Do NOT staple or tape

Checklist for Primary Source Verification Application

Specialist-in-Training

The following checklist will help you collate the required documents. If you do not provide these documents or if the documents you provide are not clearly legible or in full, processing of your application will be delayed. For details about the required documents, see the information available on the AMC website (www.amc.org.au).

Have you answered all questions on the Primary Source Verification ApplicationSpecialist-in-Training form?

Have you included certified copies of your final ‘hang on the wall’ primary qualification and your specialist qualification(s)?

Have you completed in full the Primary Source Verification of Medical QualificationsAuthorisation for Release of Information Form and have you attached to it a current (no older than 12 months) colour passport-sized photograph with your name printed clearly on the back?

Have you included certified copies of the English translations of your primary or specialist qualifications if those qualifications are in a language other than English? The translations must have been done by an authorised translation service. The AMC translation policy is available at http://www.amc.org.au/ index.php/ass/apps/trans.

Have you submitted certified evidence of your identity according to the AMC’s proof of identity requirements available on the AMC website (www.amc.org.au)?

Has your documentation been certified correctly, dated and signed (with name and title printed) by the same eligible witness who witnessed your Primary Source Verification ApplicationSpecialist-in-Training form? A list of eligible witnesses can be found on the AMC website (www.amc.org.au). If a different eligible witness certified your documentation or witness your application, you must correctly complete a statutory declaration to explain why a different witness was used.

Have you provided a statutory declaration or change of name documentation for any name variations in your application or any of the supporting documentation you are submitting?

Have you included a cheque or money order or your credit card details for payment of the application fee?

Have you attached to any document that is in a language other than English an English translation conducted by an authorised translation service or a professional translator? Has that authorised translator included their details on the actual translated page or, if on a separate page, have they correctly bounded it (no staples)?

IMPORTANT NOTE Assessment will not begin until the AMC has processed payment of the assessment fee and received all assessment documentation. If any required documents are not included or are not certified correctly, your application will not be complete and the assessment process will be delayed. The Primary Source Verification ApplicationSpecialist-in-Training form will NOT be accepted if sent by email or facsimile.