°| Re t fi Official USMLE® TI ipt ECFMG Request for an Official ranscrip\ = AUSMLE transcript includes a complete results history of all USMLE Steps or Step Components you have taken and for which results are available, as of the date the transcript is processed. For more information, see Scores & Transcripts on the USMLE website. = To obtain your USMLE transcript, or to have it sent to a third party, please complete and sign this request form. (If you have applied for or taken USMLE Step 3, or if you want your USMLE transcript sent to a state medical board, do not use this form. See “Important Notes” below.) = To submit payment, complete all information requested on the Payment for Service(s) Requested (Form 900), which is included with this request form. = You should check “USMLE Transcript’ in item 2 of the payment form. Submit the completed payment form with your request for an official USMLE transcript. = Return the completed Form 172 along with payment (Form 900) by fax, to (215) 386-3185, or mail to ECFMG, 3624 Market Street, 4th Floor, Philadelphia, PA 19104-2685 USA. You may request a maximum of 10 transcripts on each request form. Include a payment of US$65.00 for each form you submit. = Please allow approximately four weeks for your request to be processed. = Direct questions to ECFMG at (215) 386-5800 or info@ecimg. org. Important Notes: = ECFMG does not provide USMLE transcripts to state medical boards or ather licensing authorities. If you want your USMLE transcript sent to a state medical board, you must contact the FSMB at (817) 868-4000 or www.fsmb.org. To provide your ECFMG certification status to these entities, contact ECFMG's Certification Verification Service or visit www.ectmg.orgicvs. ‘Individuals who have applied for or taken USMLE Step 3 must contact the FSMB at (817) 868-4000 or www.fsmb.org to request a transcript = ERAS Applicants: Do not use this form to request transmission of your USMLE transcript via ERAS, Instead, log into www myeras.aame.org, USMLE/ ECFMG Ooo I 4 Identification Number: -| -| Fata Tat Rat Somaya) ina 1o release an offical copy of my USMLE Transcript tothe individual(s sted on page 2 of this form. 3 Thay ashore £6 a Ta CA ABTS oa ‘The fee for requesting one through 10 official USMLE For office use only transcripts is $65.00. To submit payment, complete all information requested on the Payment for Service(s) Requested (Form 900). Form 900 is included with this request form, You should check “USMLE Transcript” in item 2 of the payment form, ‘Submit the completed payment form with your Request for ‘an Official USMLE® Transcript This form Is avaliable on the ECFMG website at vwrw.octmg.org.sme ecruc entncatonnumber: IL) IJ) 4 Enter the Tae tae fame and ‘ess Yor individual or ination thats er 0py of your oes ey ‘SataProvnce oy BiProvnce USMLE rans. bp not enter state mmescal Boards o vee vm siner Teensing sutras ‘raeranton ‘gananton Instead, coe imporant Nate" on age a Saomce ow Shree ERAS opean’: Donot use thi form to request of your im 7 Ushi transept via ERAS, ‘rarer ‘rganaeton Inston, og to yer 7 meng. 7 Saronce ow SPs a Saree ow SaiProce ee Sairownce oy SeiPronnceECFMG] Parmentier seniceis) Requested P Form 900 A Y 3 MAILICOURIER: ECFIG, 3524 Market Stoo, ah Foor, Phadelpha, PA 191042986 USA M TELEPHONE: (215) 386.5000 + FAX: (216) 386.3185 » INTERNET: wr 0309.06 E USMLE*/EcrMG® 1 Identification Number: 7 ~ | N Enter your T Idotdeaton Nonber Frat Wats Nada Nanos Enleryou ast Names) (umame OF Famy Name) sor Sete 5 auiv) 2 Application for ECEMG Cortiication ($85) D1 EcFnG Exam Chart ($50 per request form - up to three copies) Anpicaton or USMLE Sep Sep 2 CK SEES per exam) ECF CSAHatay Cra (50 pe request frm up oT copies) tndeate 1 5) _agpheatan for USMLE Step 2S (1 05 per xan) D_cvs=siate Boas 535) ferwnicn | Cl extrson of USHLE stop Step 2CK Egbity Period. EvSP (ut VISA) 285) town 1 een D_epteae EoFMG Ceres (50) payment. aural change, VSMKE Step Sep 2 CK 1 Name Change on ECFMG Cerca ($50) 1 Score Recheck: USMLE Step 1/Step 2 CK/Step 2 CS. C1 Fite Copy Fee ($25) €50 pe exam Taran Feo = Maia! Schoo! Tanke ($200) 11 ERAS® Token $105) ERAS Applicants: Do NOT use this ‘emt pay er aramsaonofYou USMLE tansrpr wa” “nlenaonalteedevey surcharges ko may 994 ad must be ERAS, sted, ogo AAMC NYERAS webs inked pyment arth of fesse the CoP MG ete at 1 UsiLe Transept $85 per eaves! fom — upto vawmecing. ras. ‘ranacps) ERAS Apptcant Oo NOT use ts savous tancloer Spe {oro pay fr Waranssin of your USMLE varscp ia us SataestOmer (pect ERAS. stead, gin 9 AAMC MYERAS websto Os 3 ) O charge my creat card saleta tp, Date cra ara . neta ot wumbor wonewvean:| | |/ payne oo amplte al chock One: Cvs Clmasrercago C1 oiscover AMERICAN ExPRESS comaton ‘ume Name of ard Holder: oonor Arass of Card Hoda: sendeash ony stat: count ZipiPostal Code: By signing below | authorize ECFNG io charge my cred cardin the amount ndcaled above Signature of Card Holder ©) 1 mycheck, bank drat, or money order made payable to ECFMG is enclosed, Payment must be made in US. funds thyough @ US. bank. 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