Request to Change Applicant Biographic Information Form 182

Request to Change Applicant Biographic Information

Form 182

To change the name in your ECFMG

record, you must submit Form 182 and the required documentation, as

described below. Although you can check the name in your ECFMG record using ECFMG’s On-line Applicant Status

and Information System (OASIS), you cannot use OASIS to change your name. To correct your date of birth,

you must submit Form 182 and the required documentation. To correct your gender, you must contact ECFMG

Applicant Information Services at (215) 386-5900 or [email protected] for more information.

You can check and update the contact information, including address of residence, phone and fax numbers, and

e-mail address*, in your ECFMG record on-line using OASIS. You can access OASIS on ECFMG’s website at www.

ecfmg.org.

INSTRUCTIONS

• You may use this form to request changes to the name and date of birth in your applicant record. Complete all

sections on pages 3 and 4 of this form, and submit these pages to ECFMG at the e-mail or mailing address listed

on page 3.

• If you are requesting a change of name, you must:

1) Read the ECFMG Policy on Name Changes on page 2 of this form,

2) Complete Form 182 and sign it in the appropriate section,

3) Attach a scanned image of the acceptable documentation for name change (see policy on page 2),

4) Submit Form 182 to ECFMG. ECFMG will notify you when your name has been changed in your

ECFMG record. If your request cannot be processed because you did not submit acceptable

documentation or it was otherwise incomplete, ECFMG will notify you.

• If you are submitting this request to update your name on the Certication of Identication Form

(Form 186) as part of your Application for ECFMG Certication, you must e-mail a scanned image

of your completed Form 182 and documentation to [email protected]. You must wait

to receive ECFMG e-mail conrmation that the name has been changed in your ECFMG record before

you may proceed with your Certication of Identication Form (Form 186). You will be notied regarding

the status of your request within approximately 10 business days of receipt of your completed Form 182 and

documentation.

• If you are requesting a date of birth correction, you must:

1) Read the ECFMG Policy on Date of Birth Correction on page 2 of this form,

2) Complete Form 182 and sign it in the appropriate section,

3) Include a scanned image of one of the acceptable documents for date of birth correction (see policy on

page 2),

4) Submit Form 182 to ECFMG. ECFMG will notify you when your date of birth has been corrected in your

ECFMG record. If your request cannot be processed because you did not submit acceptable documentation

or it was otherwise incomplete, ECFMG will notify you.

• If you are submitting this request in conjunction with an Application for ECFMG Certication

or an exam application, you must e-mail a scanned image of your completed Form 182 and

documentation to [email protected]. You must wait to receive ECFMG e-mail

conrmation that the date of birth has been changed in your ECFMG record before you may proceed

with your application. You will be notied regarding the status of your request within approximately 10

business days of receipt of your completed Form 182 and documentation.

* Important Note: Changing your e-mail address using OASIS does not update your e-mail address in ECFMG’s e-newsletter subscriber

lists. If you change your e-mail address and are subscribed to one or more of ECFMG’s e-mail newsletters, such as The ECFMG

Reporter,

you must update your e-mail address for each e-newsletter. Visit the Resources section of the ECFMG website at www.ecfmg.org, click on the

newsletter(s) you receive, unsubscribe your old e-mail address, and subscribe your new e-mail address.

Form 182, Rev. AUG 2023

Page 1 of 4

Request to Change Applicant Biographic Information

Form 182

ECFMG POLICY ON NAME CHANGES

You must ensure that the name in your ECFMG record matches your name exactly as it appears on your current, unexpired

passport.

If you want to request a change of name in your ECFMG record, you must complete Form 182 and provide an explanation

of the reason for the name change, accompanied by a scanned image of the appropriate document(s). ECFMG must be

able to determine from the document(s) you submit that your name has legally changed from the name currently

in your ECFMG record to the name you are requesting to appear in your record and that you are using this new

name consistently. This means that it may be necessary for you to submit more than one document to support

your name change request. For the purpose of changing your name, you must submit your current, unexpired passport

(including the pages with your photograph and the expiration date). If additional supporting documentation is required,

examples of acceptable documentation include:

• Birth Certicate

• Marriage Certicate/License (if your name change is due to marriage)

• Ocial Court Order/Name Change Documentation

• Ocial Immigration Document, including:

• U.S. Resident Alien Card

• U.S. Naturalization Certicate

• Permanent Residence Card

• Driver’s License

Attestations are not acceptable as documentation to change your name.

All documents submitted to change your name that are not in English must be accompanied by an ocial English

translation that meets ECFMG’s translation requirements. (See English Translations in the Resources section of the

ECFMG website.) All documents submitted to change your name, including translations, will become a part of your

permanent ECFMG record and will not be returned to you.

If you have a valid Certication of Identication Form (Form 186) on le with ECFMG, it will be invalidated when

the name in your ECFMG record is changed, and you will be required to complete a new Certication of

Identication Form (Form 186) before you may apply for examination.

For complete information, see Your Name and Changing Your Name in the ECFMG Information Booklet.

ECFMG POLICY ON DATE OF BIRTH CORRECTION

If your date of birth is not correct in your ECFMG record, you must complete Form 182 and provide an

explanation of why the date of birth you previously provided to us is not accurate, accompanied by a scanned

image of one of the following:

• Passport (including the pages with your photograph and the expiration date)

• Birth Certicate

Attestations and adavits are not acceptable as documentation to correct your date of birth.

All documents submitted to correct your date of birth that are not in English must be accompanied by an ocial English

translation that meets ECFMG’s translation requirements. (See English Translations in the Resources section of the

ECFMG website.)

Form 182, Rev. AUG 2023

Page 2 of 4

Request to Change Applicant Biographic Information

Form 182

INSTRUCTIONS: Complete the applicable sections in ink, referring to the instructions that accompany this form.

Sign where indicated, and return to ECFMG

by e-mail to: [email protected], or

by mail to: Intealth, ECFMG Certication Program, 3624 Market Street, 1st Floor, Philadelphia, PA 19104, USA.

(Must be

completed.)

Enter your name as it currently appears in your ECFMG record in the spaces below.

(Must be

completed.)

First Name(s)

Middle Name(s)

USMLE

/ ECFMG

Identication Number:

Name Change

(Check the box

and complete this

section ONLY if

you are requesting

a name change.)

I have read the “ECFMG Policy On Name Changes” on page 2 of this form and wish to change the name in my ECFMG record to the

name below. I am including documentation, as described on page 2.

Last Name(s) (Surname/Family Name)

Generational Sux

(Jr, Sr, II, III, IV)

First Name(s)

Middle Name(s)

Last Name(s) (Surname/Family Name)

Generational Sux

(Jr, Sr, II, III, IV)

Form 182, Rev. AUG 2023

Page 3 of 4

Enter the reason for the name change in the space below.

(Must be

completed.)

Enter your date of birth as it currently appears in your ECFMG record in the spaces below.

(Month/Day/Year)

Correction of

Date of Birth

(Check the box

and complete

this section

ONLY if you are

requesting a

correction of your

date of birth.)

I have read the “ECFMG Policy on Date of Birth Correction” on page 2 of this form and wish to correct the date of birth in my

ECFMG record to the date of birth below. I am including documentation, as described on page 2.

(Month/Day/Year)

Enter the reason for the date of birth correction in the space below.

Request to Change Applicant Biographic Information

Form 182

Form 182, Rev. AUG 2023

Page 4 of 4

Signature

(Must be

completed.)

I hereby authorize ECFMG to change the information in my applicant record as noted above.

(Note: The requested change(s) will not be made without your signature.)

Signature (Using the Latin Alphabet) Date (Month/Day/Year)

This form is available on the ECFMG website at www.ecfmg.org.