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 not
included in your original application fee; therefore, you will be required to pay a $50 fee (inclusive of
administrative fees) directly to NotaryCam, at the time of your on-line session, to certify Form 186.
NotaryCam accepts all major credit cards as well as PayPal. Visit http://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 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 · Actual size of passport page
· The passport expiration date (may be a · Clear and legible with all edges and corners
separate page from name/photo page) · In color
· The section of your passport in Latin · In (JPEG) format
characters (if the page with name/photo is · A file size of 2MB or less
not in Latin characters)

*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 [email protected] if you have
questions about NotaryCam or, if for any reason, you cannot complete Form 186 using NotaryCam.
Form 186 CHG instructions - September 30, 2020
ECFMG CERTIFICATION OF IDENTIFICATION FORM (FORM 186)

®
S0000416340
ECFMG ID Number: 0-876-601-6
CHG
Name: Erwin Handoko
Date of Birth: 21 Mar 1982
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 it may hold, 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, determinations of irregular behavior and/or removal of J-1 visa sponsorship
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, contractors, representatives, trustees, 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 and understood the ECFMG Privacy Notice, which is available on the ECFMG website at https://www.ecfmg.org/annc/privacy.html, and
consent to the collection and use of my personal information in the matter described therein.

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

Form 186, August 2021