Get Form 176 Mdb Ecfmg

This guide provides comprehensive and clear instructions for completing the Form 176 Mdb Ecfmg online. Designed for individuals seeking to submit their credentials for verification, this resource offers step-by-step assistance for each section of the form.

Follow the steps to complete the Form 176 Mdb Ecfmg.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out Item 1, 'Name.' Enter your full name as it appears on your Health Professions Council of South Africa application. Make sure to include your last name (surname) on line 1, your first and middle names on line 2, and your maiden/alternate names on line 3.
3. In Item 2, 'Gender,' check the appropriate box to indicate your gender.
4. For Item 3, 'Date and Place of Birth,' enter your date of birth in the format of day, month, and year, and make sure to include the country of your birth.
5. If you have an EICS or USMLE/ECFMG Identification Number, enter it in Item 4.
6. In Item 5, 'Contact Information,' provide a complete mailing address, telephone, fax numbers, and email address so that EICS can communicate with you.
7. For Item 6, 'Documentation,' include legible copies of required documents as specified, such as your medical school diploma and transcript. If any document is not in English, provide an official translation.
8. Optional: In Item 7, 'Courier Service,' check the boxes if you want EICS to use a courier service for sending your verification requests, providing your account number if applicable.
9. In Item 8, 'Medical School of Graduation,' fill out the name, city, and country of the medical school you graduated from and include attendance details.
10. Complete Item 9 by listing your postgraduate medical education, ensuring to provide the full names and addresses of institutions where you completed training.
11. For Item 10, enter all jurisdictions where you held medical licenses/registrations outside South Africa, detailing the status of each one.
12. Complete the Affidavit and Release by signing and dating the document. Make sure this is certified by a recognized official.
13. Fill out the Authorization for Release of Information, Documents and Records with your details and sign across the front of the attached photograph.
14. Complete the EICS Application Fee Payment Sheet, indicating your payment method and enclosing the correct fee.
15. Finally, make a photocopy of the completed EICS application for your records and submit the application packet along with all necessary documents and payment to the specified address.

Complete your Form 176 Mdb Ecfmg online today to ensure a smooth verification process.