Examination

Name

Permanent Address:

Street

Subject

State

Zip Code

Telephone

Fax

Email Address:

Mailing Address:

Street

City

If Different

State

Zip Code

Present Employment:

Name

Street

City

State

Zip Code

Date and Place of Birth:

Date

City

State

Country

Citizenship

Marital Status:
MarriedSingleDivorcedSeparated

This application is for:
MembershipFellowshipDiploma

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

you are applying for

Year Issued

Are you in good standing with the licensing board?
YesNo

Will you be able to use our certification in your state or country?
YesNo

What is your specialization?

How many years experience do you have in your specialty?

State any postgraduate experience or degree obtained

Our journal is mandatory for members. Are you willing to subscribe to the journal and pay annual subscriptions?
YesNo

Do you understand that our MEMBERSHIPS, FELLOWSHIPS AND DIPLOMAS are available in all of the listed
specializations, and these are professional DIPLOMAS AND FELLOWSHIPS NOT DESIGNED AS TRANSFERRABLE
CREDIT FOR COLLEGIATE LEVEL WORK?
YesNo

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)

A. List all research works that you have conducted or participated (type, purpose, subject matter, descriptions,
institution where it was conducted, supervisor and whether it was published; provide title, publisher and date if
possible).

B. List the publishers and dates of books, monographs, or pamphlets published (use separate paper if necessary)

C. List the titles of articles (Journals and dates) published or unpublished (use separate paper is necessary)

D. List recent seminars, medical meetings, symposiums, and conferences attended:

E. List awards and honors received:

Have you ever applied to this organization for admission into any of it’s programs at any time?
YesNo

Languages spoken or written:
EnglishFrenchSpanishArabicOther

Available Specialties
Addictive MedicineAdministrative MedicineAdolescent MedicineAlternative MedicineMedical AdministrationAerospace MedicineAllergy / ImmunologyAnesthesiologyBiomechanic / Manual MedicineCardiologyCommunity MedicineComputer MedicineCorrectional MedicineCritical MedicineDentistryDermatologyEmergency MedicineEar/Nose/Throat - ENTEndocrinologyEpidemiologyForensic MedicineGeneral Practice / FamilyGastroenterologyGeriatric MedicineGroup Practice MedicineHematologyIndustrial MedicineInfectious DiseaseInternal MedicineInternational HealthJurisprudenceMaternal Child HealthMicrobiology / ParasitologyMedical EducationMedical PsychologyMilitary Medicine & SurgeryMinimally Invasive Spine ProceduresMinimally Invasive SurgeryNaturopathic MedicineNephrologyNeurologyNeurosurgeryNutritionObstetrics & GynecologyOccupational MedicineOncologyOpthamologyOrthopaedic SurgeryOsteopathic MedicinePathology / LabPediatric / Child HealthPharmacologyPodiatric MedicinePublic HealthPulmonary MedicinePreventive MedicineProctologyPsychiatryPsychotherapyRadiologyResearch & MethodologyRheumatologySport MedicineSurgery - All specialtiesTropical Medicine & HygieneTropical Medicine & SurgeryTuberculosis & Chest DiseasesUrologyVenerologyVeterinary MedicineOther Specialties (specify)