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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-intraining 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.

Updated January 2012

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PRIMARY SOURCE VERIFICATION APPLICATION SPECIALIST-IN-TRAINING INTERNATIONAL MEDICAL GRADUATES FOR MEDICAL BOARD OF AUSTRALIA PURPOSES. Prcd by: …………………... Country CONTACT DETAILS Home phone Work phone Mobile Facsimile Email address PRIMARY MEDICAL QUALIFICATION Country of training Year qualified Primary qualification Year awarded Name on diploma Medical school Controlling university Updated January 2012 Page 2 of 7 . Rcpt: ……………………… State Postcode Amount: ………………….. IDENTITY OF APPLICANT Family name (Surname) Given names OFFICE USE ONLY Male Day Month Year Female Date of birth FILE NUMBER Country of birth ADDRESS FOR CORRESPONDENCE Address DATE RECEIVED STAMP Code: …………...………….

au). If submitting a statutory declaration.org. Please note that meeting the AMC’s requirements for identification will not necessarily satisfy the Medical Board of Australia’s proof of identity requirements. visit the AMC website (www.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 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. ensure that all variations are explained and state which name you wish to be known as for AMC purposes. you are required to attach certified documentary evidence of your change of name.amc. Applicants will need to provide proof of personal identity by way of submission of two (2) types of identification documentation. Tick this box if you have submitted certified evidence of identification Updated January 2012 Page 3 of 7 . To view these requirements. EVIDENCE OF IDENTITY All applicants applying through the Australian Medical Council (AMC) must satisfy the AMC of their identity.

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. Card expiry date Month Cardholder’s signature Date Bank cheque Money order (payable to Australian Medical Council) Credit card (see below) (Note: MasterCard/Visa debit cards are not accepted) Credit card number Year Day Name of person to whom the AMC receipt is to be issued Month Year PAYMENT FOR ASSESSMENT IS REQUIRED EVEN IF EICS VERIFICATION HAS ALREADY BEEN CONFIRMED EICS VERIFICATION Since January 2006. Information collected by the AMC may be used for administering the assessment of the Primary Source Verification—Specialist-in-Training Application and provided to officers of the specialist colleges and the Medical Board of Australia. Applicants will continue to apply to the AMC for initial assessment. applicants will be able to continue with the AMC examination or the specialist assessment. the candidature will be confirmed. The documents will be forwarded to the ECFMG for verification through the original issuing university or institution. 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. Consent to collect information Signature Date Day Month Year Updated January 2012 Page 4 of 7 . until the verification has been confirmed. Australian Medical Council Limited. The AMC will not be able to issue a final AMC Certificate after successful completion of the AMC examination process. KINGSTON ACT 2604. PO Box 4810. including EICS verification – AUD230 Payment can be made by PLEASE PRINT CLEARLY Credit card type MasterCard Visa Note: Recording the expiry date will be taken as consent to record the credit card details and process payment. Subject to the vetting of their documents by the AMC. Australia. When confirmation of verification is received by the AMC. EICS NUMBER USMLE NUMBER PRIVACY Your privacy is respected by the AMC. 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.METHOD OF PAYMENT I wish to have my primary and/or principal/highest specialist qualifications assessed.

Updated January 2012 Page 5 of 7 . ** The title of the witness must be written (e. of (Name) (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 Qualifications—Authorisation for Release of Information Form I have familiarised myself with the AMC’s requirements. * The person witnessing this Declaration must be the same person who certifies the documents of the applicant. and the information provided. as well as with its Privacy Policy The statements made.g. town.DECLARATION BY APPLICANT Please print clearly in sections below and complete all fields I. suburb or locality Before me* (Witness) the Date day of Month year Year Signature of person before whom the Declaration is made Insert official title** of witness before whom the Declaration is made Insert address of witness before whom the Declaration is made Please print name of witness in BLOCK LETTERS Contact number of witness. 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. Notary Public. in this application form and in the certified documents attached are true and complete. Justice of the Peace). procedures and policies as set out in relevant AMC publications and on its website. 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 Declared at Name of city.

as authorised by me. Jr) Date of birth Please ensure your date of birth is written in full (e. ECFMG to retain such information in ECFMG’s database for the purposes of a) b) c) addressing any further requests from AMC for verification and/or source verification in respect of my application responding to any request sent to ECFMG from an authority other than AMC.A. I further request and authorise that the requested information. Suffix (e. 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. character and other information pertaining to me. 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 First name Middle initial. representatives. documents and records be sent directly to: Educational Commission for Foreign Medical Graduates 3624 Market Street Philadelphia. federal or foreign). and release. state. hospital. PA 19104. concerning my professional qualifications and competence. Date of signature Day Month Year Signature Ensure this signature is similar to the signature on the Application Declaration. reports. clinic. to verify and/or source verify my credentials internally accessing those portions of the data which are not personal information in order to verify credentials of other persons from time to time. records or documents forwarded by me. communications. institution. U. IMMUNITY AND RELEASE I hereby extend absolute immunity to. Please clearly print your full names on the back of this photo. documents. hospitals and clinics providing information pursuant to this authorisation. records. recommendations or disclosures involving me.g. individual or any person or groups of persons must be sent directly by such persons to ECFMG. requested or received by ECFMG or AMC or any other third party. government agency (local. discharge and hold harmless from any and all liability: a) b) c) ECFMG and AMC and their respective agents. law enforcement agency or other third parties and organisations. hospital. 2. made in good faith and without malice. By my signature below.PRIMARY SOURCE VERIFICATION OF MEDICAL QUALIFICATIONS Authorisation for Release of Information Form I hereby authorise: 1. records. and their representatives.S. transcripts. institutions. I request and authorise every person. transcripts and other documents.g 23 January 1970) Updated January 2012 Page 6 of 7 . to ECFMG. to release information. I acknowledge that information. and their representatives. I understand that ECFMG will not accept such information. directors and officers any third parties and organisations for any acts. A photocopy or facsimile of this authorisation form shall be as valid as the original and valid from the date signed. professional licensing board of any state or country in which I hold or may have held a license to practise my profession. documents and records required to be furnished by another organisation. Please sign inside the box to ensure the AMC is recording your full signature PLEASE PRINT Family name/Surname Securely glue in this square a current frontview passport-sized colour photograph of yourself in the block below. government agencies. statements. or directly from me. ethics. directors and officers other licensing boards. educational institution.

if on a separate page. The AMC translation policy is available at http://www.au).org. Updated January 2012 Page 7 of 7 . For details about the required documents.org.php/ass/apps/trans. processing of your application will be delayed. If any required documents are not included or are not certified correctly. If a different eligible witness certified your documentation or witness your application. dated and signed (with name and title printed) by the same eligible witness who witnessed your Primary Source Verification Application—Specialist-in-Training form? A list of eligible witnesses can be found on the AMC website (www. If you do not provide these documents or if the documents you provide are not clearly legible or in full.amc.amc. 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. The Primary Source Verification Application—Specialist-in-Training form will NOT be accepted if sent by email or facsimile. you must correctly complete a statutory declaration to explain why a different witness was used.au/ index.au)? Has your documentation been certified correctly. your application will not be complete and the assessment process will be delayed. see the information available on the AMC website (www. Have you submitted certified evidence of your identity according to the AMC’s proof of identity requirements available on the AMC website (www.amc. 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.org.amc.org.Checklist for Primary Source Verification Application— Specialist-in-Training The following checklist will help you collate the required documents.     Have you answered all questions on the Primary Source Verification Application—Specialist-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 Qualifications—Authorisation 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.au).