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.”
7). RCPSUS Membership fee is $2800.00 USD plus $300 application fee. The $2800.00 USD fee is refundable if the application is not approved by the Committee.
Research and Publications (use separate paper if necessary)
I certify that I Voluntarily enroll and willingly support the concept of Continuing Education Programs for doctors. I am
licensed in the country where I intend to use the /Memberships, Fellowships, and Diplomas certificate (s) that I am applying for. I am
enclosing a $300 non-refundable application fee OR the complete tuition fee. I understand that no action will be taken on my
application without payment of fee and submitting all the required credentials.
I authorize full investigation of my application. My signature below is the authorization to anyone to release any
information you may request on me. I agree that my competency in clinical skills and professional qualifications will be evaluated and
the Royal College may make inquiry or release information about me concerning this matter. I agree to indemnify, release and hold
harmless the Royal College of Physicians and Surgeons and its Agents from any liabilities or torts by reason of their acts or omissions
in connection with this application. I agree to abide by the decision of the Royal College or its agents. We agree to submit to
arbitration under the American Arbitration Association for any controversy, claims, torts and tort nuisance and other related
violations. We are to submit the above controversies to above arbitrators in Detroit, Michigan, USA, and a judgment of the
competent court may enter such award of the arbitrators.
I agree to function within the limits of my competency and I guarantee and warrant that the Royal College of Physicians
and Surgeons (and its agents) assume no responsibility for any of my activities or actions.
It is understood by me that any falsification of records, misrepresentation of material facts, dishonesty, forgery, and
unethical practices will automatically render any Memberships, Fellowships or Diplomas certifications awarded to me NULL and
Void.
Under penalty of perjury, I guarantee and warrant that all information provided on all pages of this application are true and
correct. I am legally bound by the foregoing as attested to here with my signature below.
The Royal College of Physicians and Surgeons admits professionals to its organizations of any race, color, national origin,
sex, age, handicap, or religious preference in its education programs, activities, and employment as required by the Civil Rights Act of
1964 and Amendments including Title IX of the Educational Amendments of 1972.