International Medical Degree Evaluation Request Form

International Medical Degree Evaluation Request Form
Please complete this form to request evaluation of your international medical degree and supporting training documents.
Applicant Information
Full Name
First NameMiddle NameLast Name
Preferred Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Country of Residence
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical Education Background
Medical school name
Country of medical school
Degree earned
Field of study / specialization
Date of graduation
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current enrollment status
Clinical Training and Experience
Clinical training entries
Years of clinical practice
Current medical licensure status
Licensing authority
License number
Primary clinical specialty
Clinical training notes
Documents for Evaluation
Documents Available for Evaluation
Medical diploma
Cancelof
Academic transcripts
Cancelof
Course descriptions or syllabi
Cancelof
Internship or residency certificates
Cancelof
Clinical experience letters
Cancelof
Translated copies of documents
Cancelof
Evaluation Request Details
Purpose of Evaluation
Intended Use of Evaluation Report
Preferred Evaluation Type
Other
Evaluation Deadline
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Special Instructions or Additional Notes
Should be Empty: