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UCSF ECFMG Application
Department Contact Name
Dept. Contact Phone
Dept. Contact e-mail
International Medical Graduate (IMG) Biographical Information - Note For Canadians- Canadian medical school graduates are exempt from ECFMG certification but are required to obtain an ECFMG account number. Canadians may request an ECFMG account number by writing to firstname.lastname@example.org. Please do not submit form with out the account number.
IMG Last Name
IMG First Name
IMG USMLE/ECFMG ID
IMG Date of Birth
Training Program Information- A list of standard, ACGME accredited training programs can be found at
A list of non-standard ABMS programs can be found at
. In providing the name of the training track, please choose from one of these two lists as appropriate.
Please answer all these questions based on the upcoming year of training, not the current year of training.
ACGME Accredited? (Yes or No)
Program/training Track Name (
Please choose from either the ACGME or ABMS lists noted above
PGY Training Level of IMG for Upcoming Year
Program Start Date
Program End Date
Training Coordinator Name
Training Coordinator e-mail
Training Coordinator Phone
Does program provide health insurance (Yes or No)
Will IMG be starting a new training program?
UCSF Salary Amount for Training Level
Will IMG receive a salary/stipend from UCSF? (*Yes / No)
*If yes, how much?
Outside funding sources (please list amount and sources )
Total Funding Amount for program (UCSF and outside funding):
Once the ISSO receives the DS-2019 from ECFMG, what would you like us to do with the form?
Please hold it at the ISSO for pick up.
Please send it directly to the Resident/Fellow
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