2017523 ECFMGOnlineApplication

FORM186CERTIFICATIONOFIDENTIFICATONFORMMEDICALSCHOOLOFFICIAL

USMLE/ECFMGIDNumber:10307742
ReferenceCode:S0000248616
Name:MariaAlejandraPenaNavarro
DateofBirth:06Aug1996
MedicalSchool:UniversidaddeLosAndesFacultaddeMedicina(Colombia)
AttendanceDates:January2013toDecember2019
ExpectedGraduationDate:March2020
ExpectedDegreeDate:March2020

Certifyingofficialmustsignbelow

WhencompletedandsubmittedtoECFMG,thisCertificationofIdentificationForm(Form186)willbecomeapartofyourECFMGrecordandwillbeusedtoidentifyyou
whenyousubmitanapplicationtoECFMGforaUSMLESteporStepComponentwithinfiveyearsfromthedatethisformisevaluatedandacceptedbyECFMG.

SignthisForm186inthepresenceofanauthorizedofficialofyourmedicalschool.CertificationofIdentificationFormsmustbesenttoECFMGdirectlyfromtheofficeof
theofficialwhowitnessestheapplicantssignature.AllinformationonanapplicationandontheCertificationofIdentificationFormissubjecttoverificationandacceptance
bytheEducationalCommissionforForeignMedicalGraduates.

IcertifythatIamtheindividualnamedabove,amrepresentedintheattachedphotograph(s),thephotograph(s)weretakenwithin6monthsofthedateofthisCertification
ofIdentificationFormandthatthesignaturebelowismysignature.

Irequestandauthorizeeveryperson,medicalschool,university,hospital,governmentagency,orotherentitytoreleaseinformationtoECFMGbearingonthecontentof
myapplicationoranyotherdocumentsubmittedtoECFMGincluding,butnotlimitedto,records,diplomas,transcripts,andotherdocumentsconcerningmyidentity,
citizenshiporimmigrationstatus,educational,academicorprofessionalhistoryandstatus,orenrollment.IherebyauthorizeECFMGtotransmitanyinformationinits
possession,orthatmayotherwisebecomeavailabletoECFMG,bearingonthecontentofmyapplicationoranyotherdocumentsubmittedtoECFMG,including,butnot
limitedto,records,diplomas,transcripts,andotherdocumentsconcerningmyidentity,citizenshiporimmigrationstatus,educational,academicorprofessionalhistoryand
status,orenrollment,anddeterminationsofirregularbehaviortoanyfederal,state,orlocalgovernmentaldepartmentoragency,toanyhospitalortoanyother
organizationorindividualwho,inthejudgmentofECFMG,hasalegitimateinterestinsuchinformation.ForfurtherinformationregardingECFMG'sdatacollectionand
privacypractices,pleaserefertoourprivacypolicyavailableontheECFMGwebsiteatwww.ecfmg.org/annc/privacy.html.

SignatureofApplicant(inLatinCharacters)X________________________________________________________

Date:_______________(day/month/year)

CertificationbyMedicalSchoolOfficial:
Iherebycertifythatthephotograph,signatureandinformationenteredinallpartsofthisform,includingmedicalschool,attendance
dates,andgraduationanddegreedates,accuratelyapplytotheindividualnamedaboveandthatthisindividualisastudentofthe
institutionindicatedbelow.

SignatureofMedicalSchoolOfficial(inLatinCharacters)X______________________________________________
(SignaturemustmatchexactlythesignatureonrecordwithECFMG)

Date:_______________(day/month/year)

____________________________________________________________________________________________
PrintName(inLatinCharacterswithEnglishtranslation,whereapplicable)

____________________________________________________________________________________________
OfficialTitle(inLatinCharacterswithEnglishtranslation,whereapplicable)

________________________________________
Institution

MailTo:IWAECFMG3624MarketStreet,4thFloor,Philadelphia,PA191042685USA
Form186TypeA,Rev.Sep2015

Yes.IhaveprintedthisCertificationofIdentificationForm.

https://iwa2.ecfmg.org/cifbymedschool.asp 1/1