Online Application

Name:
Permanent Address:
Mailing Address:
Present Employment:
Date and Place of Birth:
List all educational institutions attended since Secondary or High School, including professional schools and certificates, diplomas and degrees obtained. Use additional paper if necessary
State the name of the state or country where you are licensed to practice your profession and where you expect to use the CME certification from this college
With the completed application, I am enclosing the following required document (for initial processing) with my application
1). Copy of professional degree, certificates or diploma;
2). Copy of license to practice medicine where the certificate (of this college) is to be used;
3). Item #16 above;
4). A detailed curriculum vitae or bio data;
5). Passport sized photo with name and signature on back;
6). Non-refundable application fee of $300.00 for determination of eligibility. Payment must be made in USA dollars, traveler’s check, money orders, and bank checks are all acceptable and made payable to: “The Royal College of Physicians and Surgeons USA.”
Research and Publications (use separate paper if necessary)