Oman Medical Specialty Board ‫المجلس العماني لالختصاصات الطبية‬

International Foundations of Medicine (IFOM) PHOTO

Clinical Science Examination (CSE)
Application Form
1. Exam Date: 14th October 2016 15th October 2016
2. Candidate Information:
Name (as in Passport): _________________________________ Nationality: ___________
Date of Birth: __________ Place of Birth: ________________ Age: ________________
Gender: Male Female Marital Status: _____________________
Staff #: ______________________________ Sponsor: _________________________

3. Passport Information:
Passport No: __________________________ Expiry Date: ________________
National ID Card No. ____________________ Expiry Date: _________________

4. Contact Details:
Telephone (Home): ______________ Mobile: ______________ Fax: _________________
Mailing Address: ______________________________________________________________
E-mail: _______________________________________________________________________
In Case of Emergency, Person to contact:
Name: _______________________ Tel. No. (Home): ____________ (Mobile): __________
Relationship to Applicant:_______________________(E-mail): __________________________

5. Medical Education:
Institution Name: ________________________________ Country: ____________________
Date of Graduation: __________________
Language used in Medical College: English Arabic Others: __________
Internship: Completed Ongoing Institution: ________________________
Dates (From): _______________ to ______________
 I authorize OMSB to conduct source verification of my MD credentials from the Institution
stated above
6. Previous OMSB Selection Exam/IFOM Clinical Science Examination (CSE):
Have you previously sat for the IFOM CSE Exam?  Yes  No
If yes, when and where? _________________________________________________________
Oman Medical Specialty Board ‫المجلس العماني لالختصاصات الطبية‬

7. Grade Release Consent:

I consent to the NBME to release my IFOM CSE score report to OMSB.
I authorize OMSB to send my score report to my Medical School.

DECLARATION
I,_______________________________, hereby certify that I have attended ___________

/ /
_________________________ Medical School from Day Month Year and have graduated with

/ /
a Degree in Medicine on Day Month Year .

Name: _______________________________ Date: ___________________

Signature: ___________________________________

FOR OMSB USE ONLY

Complete application form must include the following documents:
 Photocopy of Medical Degree
 Photocopy of MD Transcript
 Photocopy of Internship certificate (if applicable)
 2 Photos (Recent Passport Size)
 Copy of Civil ID card
 Examination Fees paid in the amount of 40 OMR (Official Receipt Number: ___________)
 Performance Report of IFOM-CSE Self-Assessment Examination

APPROVAL:
 Approved
 Not approved Reason: _________________________________________________

Authorized Signatory: ______________________________ Date: _______________________

Stamp: