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US International Medical Graduate Limited MA License For

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US International Medical Graduate Limited MA License For All documents must be sent directly to your BMC training program’s office, NOT to the Mass Board of Registration in Medicine. Anything sent to the Board will need to be duplicated and sent to BMC. International Medical Graduate Checklist 1. Name Printed on Top of each page 2. Every Question is answered (n/a is unacceptable) 3. Signed & Dated Page 6 of application 4. Signed & Dated Authorization for Release 5. Provided explanation if you attended medical school for more than 6 years 6. Attached an up‐to‐date CV in Month/Year format a. All 30 day+ gaps will require a separate letter of explanation 7. Completed Medical Education Verification Form, include Medical School transcripts 8. Notarized Medical School Diploma 9. Notarized ECFMG Certificate + Request Online Status Report 10. Request Exam Score Transcripts (USMLE, COMPLEX, LMCC) 11. Only If Applicable: a. Provide English Translations of any documents in the home country language. i. Translations must be from a US Company or from the Medical School with Medical School Seal on each page. b. Social Security Affidavit; Submit if you do not currently have a US Social Security Number c. Supplemental Forms; submit if you answered YES to any questions from 16 through 35 d. Letter from the director of your most recent training program if you did not complete the program e. Evaluation Form; Completed by your most recent Program Director f. License Verification Form; submit one form for each state you have held a Full Medical License in g. Medical Education Verification Form B; applicable only to those who will graduate Medical School after submission of this application h. Change of Name Form; Submit if you have ever changed your name FAQs 1) How do I request my “Exam Score Transcripts”? a. USMLE: https://s1.fsmb.org/trol/ Have transcripts sent to your program office. b. COMLPEX: http://www.nbome.org/ c. MCCQE: www.mcc.ca 2) Where do I request an “ECFMG Online Status Report”? a. http://www.ecfmg.org/cvs/requesting‐status‐report.html 3) Can I use FCVS to submit my medical school data? a. Yes. You will need to request that the FCVS send the material electronically to the Mass Medical Board; they are no longer accepting packets via mail. 4) If I am currently outside the country how can I get documents notarized or translated by US Companies?!?! a. All US Embassies should have someone on staff that can notarize documents for you. If the Embassy does not offer translation services contact your program office at BMC to assist you. DON’TS Do not print this application double sided, single sided only Do not include the $100.00 fee with your application; BMC covers the cost of limited licenses for all unionized housestaff Do not submit any of these pages as pdf scans with electronic signatures; the Mass Board will not accept, it must be original documents with original handwritten signatures Application #: ______________________ For Board Use Only Commonwealth of Massachusetts Board of Registration in Medicine 200 Harvard Mill Square, Suite 330, Wakefield, MA 01880 Telephone: (781) 876-8210 Fax: (781) 876-8383 www.mass.gov/massmedboard INITIAL LIMITED LICENSE APPLICATION IMPORTANT: Read the accompanying instructions. Print legibly or type your answers. Enclose a $100.00 check or money order payable to the Commonwealth of Massachusetts. This fee is non-refundable. Full Disclosure: Please review each question carefully to ensure your answers are accurate prior to submitting your application. You are personally responsible for all information disclosed on your application, including any responses that may have been completed on your behalf by others. It is imperative that you honestly and fully answer all questions, regardless of whether you believe the information requested is relevant. Your responses on your application are evaluated as evidence of your candor and honesty. An honest “yes” answer to a question on your application is not definitive as to the Board’s assessment of your present moral character and fitness to practice, but a dishonest “no” answer may be evidence of a lack of candor and honesty, which may be definitive on the character and fitness to practice issue. Please be advised that a false response to any of these questions may be grounds for denial of licensure and reported to the appropriate data banks. CHECK ONE: Graduate of a Medical School in the United States, Canada, or Puerto Rico (USMG) Graduate of an International Medical School (IMG) Are you submitting primary source documents (medical education, previous postgraduate training, etc.) for licensure through the Federation Credentials Verification Service (FCVS)? Yes No SECTION A: Sworn Statement to be completed by applicant 1-A. (Entire Last Name) (First Name) (Middle Name) (Suffix) 1-B. Other Name(s) Used: List any other name(s) you have used which may appear on your identifying documents, such as medical education and examination records. If not applicable, check here: (Entire Last Name) (First Name) (Middle Name) (Suffix) 2. Current Street Address: City: _______________________ State or Province: _____________________ Zip: Country: Telephone Number: 3. Date of Birth: _____/_____/____ Place of Birth: Month Day Year State (or country if not United States) Initial Limited Lic App – Form 2 (Application), Page 1 of 15, Rev. 02/18 PRINT NAME E-mail Address 4. Sex: Male Female 5. U.S. Social Security Number: ______ - _____ - _________ 6. Name of Massachusetts Postgraduate Training Program: Street Address City Postgraduate Training Specialty: PRE-MEDICAL EDUCATION 7. Name of premedical school(s): Location: (City, State, Country) MEDICAL EDUCATION 8. Name of medical school(s): Location: (City, State, Country) Date of Graduation: ______/_____/________ Month Day Year Degree: M. D. D. O. Other (specify) ___________________________________________ If you answer “yes” to any of the following questions, you must provide a detailed explanation and arrange for the appropriate institution to submit copies of all official documentation and correspondence related to the underlying occurrence or action. Documents should be sent directly to you in a sealed envelope. 8-a. While enrolled in college, medical school or graduate school, were you ever Yes No the subject of any disciplinary action? (This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.) 8-b. Have you ever been terminated from medical school? Yes No 8-c. Have you ever withdrawn or transferred from a medical school? Yes No 8-d. Have you ever been granted a leave of absence by a medical school? Yes No (This includes a leave for research, public service, participated in a joint degree program such as an M.D./Ph.D. program, medical leave, or for any other “personal reasons”.) Initial Limited Lic App – Form 2 (Application), Page 2 of 15, Rev. 02/18 PRINT NAME 8-e. Have you ever been placed on probation or remediation by a medical school Yes No or graduate school? 8-f. If you are a US or Canadian graduate, did you take more than four (4) years Yes No to complete medical school; or if you are an international medical graduate, did you take more than six (6) years to complete medical school? POSTGRADUATE TRAINING 9. Have you ever or are you currently engaged in postgraduate training in the U.S. Yes No or Canada? Name of U.S. or Canadian Postgraduate Training Program: City: _____________________________________________________ State: Training Dates: From: _____/_____/_____ To: _____/_____/_____ Postgraduate Training Specialty: (Attach a list of any additional postgraduate training in the United States or Canada.) NOTE: If you answered “Yes” to Question 9, please answer Questions 9 a. – i. If you answered “No” to Question 9, please go to Question 10. If you answer “yes” to any of the following questions, you must provide a detailed explanation and arrange for the appropriate institution to submit copies of all official documentation and correspondence related to the underlying occurrence or action. Documents should be sent directly to you in a sealed envelope. 9-a. While enrolled in postgraduate training, were you ever the subject of any Yes No disciplinary action? (This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.) 9-b. Have you ever been suspended, terminated, or dismissed from any Yes No postgraduate training program? 9-c. Have you ever had to repeat a year of postgraduate training? Yes No 9-d. Have you ever withdrawn or transferred from a postgraduate training Yes No program? 9-e. Have you ever been granted a leave of absence from a postgraduate training Yes No program? (This includes a leave for research, public service, medical leave, or for any other “personal reasons”.) 9-f. Have you ever been placed on probation or remediation by a postgraduate Yes No training program? Initial Limited Lic App – Form 2 (Application), Page 3 of 15, Rev. 02/18 PRINT NAME 9-g. Were any limitations or special requirements imposed on you because of Yes No questions of competency or disciplinary problems? 9-h. Did you ever receive partial or no credit for a postgraduate training program? Yes No 9-i. Have you ever had a postgraduate training program contract not be renewed? Yes No 10. List states (abbreviations) where you ever had a full license to practice medicine. None 11. Please indicate all the licensing examinations that you have have completed with a passing score: USMLE: Step 1 Step 2 (CK) Step 2 (CS) Step 3 COMLEX: Level 1 Level 2 (CE) Level 2 (PE) Level 3 LMCC Other ____________________________________________ YES NO 12.
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