Hamad Medical Corporation

Department of Medical Education

GME Office
IFOM CSE

Photo

IFOM Clinical Science Examination (CSE) Application Form

Please read FAQ before completing the Application Form. TYPE or Print
1. Candidate Name:________________ _______________ _________________
(As in Passport)

First

Middle

Family

Date of Birth: ____/___/______ Place of Birth: ____________ Nationality:_________________

dd

mm

Gender: Male

yyyy

Female

2. Passport Information:
Passport No:_____________________ Expiry Date: ____/___/_____
dd

mm

yyyy

Residency Permit No.: _____________________Expiry date: ___/____/____

(For those who are Residents in Qatar)

dd

mm

yyyy

3. Contact Details:
Tel. with country code (Home): . (Mobile): (Fax): ..
Mailing Address: ...
E-mail: .
In Case of Emergency, Person to contact:
Name: ................................................. Tel. No. (Home): (Mobile): .
(E-mail):

4. Name of Medical College: _________________________Country:____________________

Date of Graduation: ____/_____/______ _ OR
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mm

Language Used in Medical College:

Expected date of Graduation: ___/____/_______

(for medical students)

yyyy

English

Arabic

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mm

yyyy

Others:_________________

Internship: Done Not done Institution:_________________ Dates (From): _________ to _______

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Hamad Medical Corporation

Department of Medical Education
GME Office
IFOM CSE

5. Previous IFOM Clinical Science Examination (CSE):

Have you previously sat for the IFOM CSE?...................................................................................................................
If yes, when and where?..................................................................................................................................................

6. Grade Release Consent:

Please tick as appropriate:

I consent to the NBME to release my IFOM CSE score report to HMC Medical Education.
I do not consent to the NBME to release my IFOM CSE score report to HMC Medical Education.

FOR GME OFFICE USE ONLY

7. Complete Application Form should include the following documents (1 set)

Medical Degree (Diploma) or proof of being a final year medical student

Internship Certificate
one Photos (Recent Passport Size)
Residency permit copy (if resident in Qatar)
Copy of ID used for registration (passport)
Received by: ___________________________ __ Signature________________ Date: ____________

Approved
Not Approved

Reason:______________________________________________________

Director Medical Education Signature: ______________________

Date _________

For further details about IFOM Clinical Science Examination (CSE) please visit our web page
______________________________________________________________________________________
Kindly visit HMC website- www.hmc.org.qa/cme/ to print the Application form. should be delivered in person
or by mail (post). Emails are Not accepted. HMC P.O. Box 3050 Med. Education Dept. Doha, Qatar.

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