Fillable Usmle Certification Of Identity Application printable pdf download

UNITED STATES MEDICAL LICENSING EXAMINATION®

STEP 3 APPLICATION

CERTIFICATION OF IDENTITY

NOTE: You must also submit your Step 3 application and fees in order for the FSMB to complete your Step 3 registration.

This form must be signed by a notary public/commissioner of oaths. When completed and submitted to the Federation,

this form becomes part of your USMLE records and will be used to identify you when you interact with the Federation.

This Certification of Identity is valid for Step 3 applications submitted within five years from the date of your

signature. If you need to reapply for or retake Step 3 within that time period, it is not necessary to submit another

Certification of Identity as long as this form is on file with the Federation.

USMLE ID: ______________

ATTACH PHOTO HERE

Type or print in uppercase letters.

Securely tape or glue in this

Name:

square a current front view

2”x2” color or passport

Last

First

Middle

quality photo.

(Print your full name and

SSN:___________________ Date of Birth: ___________________

USMLE id number on the

Email: _________________________________________________

back of the photo before

Daytime telephone: _______________________________________

attaching.)

I certify that I am the individual named above, represented in the attached photograph and that the signature below is my

signature. I certify that I meet the eligibility requirements for Step 3 and that the information on this form is true and accurate.

I also certify that I have read the most current version of the USMLE Bulletin of Information and all relevant instructions for

this or any subsequent Step 3 application, that I am familiar with the contents of the Bulletin and agree to abide by the

policies and procedures described therein.

Applicant Signature ______________________________________________________________

Certification of Identification

Certification by a Notary Public is required

State of _________________________

County of _________________________________

I certify that on the date set forth below the individual names above did appear personally before me and that I did

identify this applicant by: (a) comparing his/her physical appearance with the photograph on the identifying document

presented by the applicant and with the photograph affixed hereto, and (b) comparing his/her signature made in my

presence on the form with the signature on his/her identifying document.

Date of Notarization: ______________________________________________

Notary Stamp

or Seal

Notary Public Signature: ____________________________________________

Here

Commission Expiration Date: _______________________________________

The notary commission expiration date must be current and legible.

If no expiration date, such as ‘lifetime’, an explanation must be provided.

Please complete and mail this Certification of Identity form to:

Federation of State Medical Boards

Attn: Assessment Services

400 Fuller Wiser Road, Suite 300

Euless, TX 76039-3856

Revised: April 2015

Usmle Certification Of Identity Application

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