Certification of Identification Form (Form 186) Instructions

The Certification of Identification Form (Form 186) is required as part of the ECFMG certification process to
confirm your identity. Once ECFMG accepts Form 186, it typically remains valid indefinitely, and you can
apply for additional certification-related services, including applying for Step 1 and Step 2 of the United
States Medical Licensing Examination® (USMLE®).

Form 186 must be completed and notarized using NotaryCam, which provides convenient, on-line
access to professionally licensed and certified notaries. NotaryCam sessions are available on demand
and by appointment 24 hours a day, seven days a week, 365 days a year. Fees for using NotaryCam
were included in your application fee, therefore, you will not be required to pay fees to have
NotaryCam certify Form 186. Visit https://www.notarycam.com/ecfmg-cert for detailed instructions.

To use NotaryCam to complete Form 186, you will need:

· PDF file of Form 186 ECFMG provided to you

· a scanned, color image of the required page(s) of your passport
· a computer with a webcam (Visit https://www.notarycam.com/faq/ for system requirements.)

Form 186: As part of your NotaryCam session, you will be required to upload the PDF of Form 186
ECFMG provided to you (either after completion of the on-line portion of the Application for ECFMG
Certification or via a link in ECFMG’s Interactive Web Applications (IWA)). Form 186 must be
completed during the NotaryCam session, and it must be received by ECFMG within one year of the
date it was created.
Passport: As part of your NotaryCam session, you will be required to upload a scan of your current,
unexpired passport. A copy of your passport scan will be provided to ECFMG for your permanent file.
Passports are used by ECFMG for identity verification only.

THE SCAN OF YOUR PASSPORT MUST THE SCAN OF YOUR PASSPORT MUST BE:
INCLUDE:

· The page with your name* and photograph
· The passport expiration date (may be a
separate page from name/photo page)
· The section of your passport in Latin
characters(if the page with name/photo is not
in Latin characters)
· Actual size of passport page
· Clear and legible with all edges and corners
· In color
· In (JPEG) format
· A file size of 2MB or less

*Important Note: if the name, gender, and date of birth you submitted as part of the Application for
ECFMG Certification do not match exactly the same information in your passport, you cannot use
NotaryCam to complete Form 186. Please contact ECFMG’s Applicant Information Services for more
information.
Photograph: As part of your NotaryCam session, NotaryCam will capture a still photograph of you.
This image will be placed by the notary onto Form 186 and provided to ECFMG for your permanent file.
Please keep this in mind when scheduling and preparing for your NotaryCam session. Make sure you
are sitting in a well-lit area and that you are presenting yourself in a professional manner.
Contact ECFMG Applicant Information Services at (215) 386-5900 or info@ecfmg.org if you have
questions about NotaryCam or, if for any reason, you cannot complete Form 186 using NotaryCam.
Form 186 instructions - September 30, 2020
ECFMG CERTIFICATION OF IDENTIFICATION FORM (FORM 186)

S0000340263
®
ECFMG ID Number: 1-113-168-7
Name: Richard Brownlow Whitmore
Date of Birth: 04 Jan 1994
Gender: Male

IMPORTANT NOTE: When completed and submitted to ECFMG, this Certification of Identification Form will become part of your ECFMG record.
All information on the Certification of Identification Form is subject to verification and acceptance by ECFMG. This form will be used to identify you
when you submit an application to ECFMG for any of its programs or services, including an application for a USMLE ® Step or Step Component.

CERTIFICATION OF IDENTIFICATION BY OFFICIAL (To be completed by official)

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 printed hereto, (b) comparing his/her physical appearance with the passport
photograph, and (c) comparing his/her original passport with the copy of the attached passport.

The statements in this document were subscribed and sworn to before me by the individual.

X_______________________________________________________________________ ____________________________________________________
Signature of Official Date (mm/dd/yyyy)

APPLICANT RELEASE OF INFORMATION AND CERTIFICATION (To be completed by physician)

Release of Information Authorization

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 request or any 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 request 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, and determinations of irregular behavior 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.

I also extend absolute immunity to, and release, other agencies, medical schools, universities, institutions, hospitals and clinics, and registration and licensing
authorities providing information, their employees, representatives, directors, and officers, and any third parties and organizations for their acts, communications,
reports, records, diplomas, transcripts, statements, documents, recommendations, or disclosures involving me, made in good faith and without malice, requested by
ECFMG.

I HAVE READ, UNDERSTOOD, AND AGREE TO THIS RELEASE OF INFORMATION AUTHORIZATION AND I INTEND TO BE LEGALLY BOUND BY IT.

Certification
I certify that I am the individual named above, am represented in the attached photograph, the attached passport is a copy of the passport that was issued to me, and
that the signature below is my signature.

I hereby certify that I have read, understood, and agree to all of the above statements. I also certify that I have read the Policies and Procedures Regarding Irregular
Behavior and agree to abide by these policies and procedures. I certify I understand that, as provided in the Policies and Procedures Regarding Irregular Behavior,
among other things, ECFMG may find that submission of falsified documents to ECFMG during the certification process constitutes irregular behavior, which could
result in actions including permanent revocation of or permanent bar to ECFMG Certification, and permanent annotation of my ECFMG record, among other things. I
also certify that I have read, understood and agree to the ECFMG Privacy Notice, which is available on the ECFMG website at
https://www.ecfmg.org/annc/privacy.html.

X___________________________________________________________________________________________ ________________________
Signature of Applicant Date (mm/dd/yyyy)

Form 186, September 2018