Special Purpose Examination (SPEX GENERAL APPLICATION INSTRUCTIONS
Special Purpose Examination (SPEX®) GENERAL APPLICATION INSTRUCTIONS ELIGIBILITY SPEX is designed for physicians who hold or have held a valid, unrestricted medical license in a United States or Canadian jurisdiction. To be eligible for the SPEX you must meet all eligibility requirements established by the Federation of State Medical Boards (FSMB) and the state medical board for which the SPEX is being taken. APPLICATION MATERIALS Your application materials should include the SPEX Application, SPEX Information Bulletin, and these General Application Instructions. Be sure to read the SPEX Information Bulletin carefully before completing the application. COMPLETING THE APPLICATION Part A: Complete Part A in its entirety, following the instructions provided for each item on the application. Code lists are included with the instructions. Part B: To be completed by the Medical Licensing Authority for which SPEX is being taken. Identification page: One 2” x 2” passport type photo is required. Print your full name on the back of the photo attach to the identification page. Complete the requested information, including your signature under the photo. The identification page must be notarized, and the notary seal or stamp must fall partly on the photo and partly on the signature under the photo. A photocopy of your medical license is required for Board Sponsored and Self-Nominated applications. TESTING ACCOMMODATIONS Reasonable accommodations are provided to examinees with documented disabilities as defined by the Americans with Disabilities Act as amended in 2008, together (“ADA”). If you are a disabled individual covered under the ADA and require test accommodations, contact the FSMB for information regarding procedures and documentation requirements. This information is also available from the website at www.fsmb.org. In all cases, requests for testing accommodations must be made in writing at the time the SPEX application is submitted. PAYMENT INSTRUCTIONS The fee for SPEX is $1300, payable by check or money order to the FSMB. Payment must be submitted with the application. $650 of the SPEX application fee is nonrefundable. APPLICATION MAILING INSTRUCTIONS Mail your completed application and payment to the Medical Licensing Authority for which SPEX is being taken. PROCESSING THE APPLICATION Applications are processed by date of receipt at the FSMB offices. Allow approximately one to three weeks for processing once the FSMB receives your application from the medical licensing authority. You are advised to 1 SPEX Basic Service Gen Inst 11/2014 consult the board for their current application processing time and add this to the FSMB’s two-to-four week processing time. SCHEDULING THE EXAMINATION You will receive a Scheduling Permit with detailed information on how to schedule the exam at a Prometric Testing Center. SPEX is available across the nation throughout the year. You will have approximately 90days in which to schedule and complete the SPEX. You must present your permit and an unexpired government issued form of identification with your photograph and signature (such as a driver’s license or passport) to be admitted to the testing center. ELIGIBILITY EXTENSION If you need to extend your eligibility period, you may submit an eligibility extension request for review. If your request is approved, a one-time contiguous 90-day extension may be granted. To request an extension, you must complete the Eligibility Extension request form and submit with a $65 processing fee. SCORES Scores will be released approximately two to four weeks after the exam has been taken. ADDRESS CHANGES Correspondence regarding your application, scheduling information, and scores will be directed to the address provided on your application. Therefore, it is essential that a correct address be provided and that appropriate changes are submitted in writing to: Attn: Assessment Services Federation of State Medical Boards 400 Fuller Wiser Road, Suite 300 Euless, TX 76039-3856 2 SPEX Basic Service Gen Inst 11/2014 Board Codes (Alphabetical) 001 Alabama 002 Alaska 056 American Samoa 003 Arizona 903 Arizona Osteo 004 Arkansas 005 California 905 California Osteo 006 Colorado 007 Connecticut 008 Delaware 009 District of Columbia 010 Florida 910 Florida Osteo 011 Georgia 055 Guam 012 Hawaii 013 Idaho 014 Illinois 015 Indiana 016 Iowa 017 Kansas 018 Kentucky 019 Louisiana 020 Maine 021 Maryland 022 Massachusetts 023 Michigan 024 Minnesota 025 Mississippi 026 Missouri 027 Montana 028 Nebraska 029 Nevada 030 New Hampshire 031 New Jersey 032 New Mexico 033 New York 034 North Carolina 035 North Dakota 086 Northern Mariana Islands 036 Ohio 037 Oklahoma 038 Oregon 039 Pennsylvania 053 Puerto Rico 040 Rhode Island 041 South Carolina 042 South Dakota 043 Tennessee 044 Texas 045 Utah 046 Vermont 054 Virgin Islands, United States 047 Virginia 048 Washington 948 Washington Osteo 049 West Virginia 050 Wisconsin 051 Wyoming Country Codes (Alphabetical) 118 120 125 056 127 128 103 129 130 132 138 107 143 154 156 111 157 155 113 160 162 164 090 165 166 170 171 173 Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Azores Bahamas Bahrain Balearic Islands Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan 176 668 178 180 187 115 970 116 945 191 198 207 211 215 217 098 114 219 104 225 228 101 231 243 108 109 Bolivia Bonaire Bosnia-Herzegovina Botswana Brazil British Antarctic Territory British East Africa British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos Islands 3 264 265 727 117 100 270 273 275 667 968 280 281 966 286 297 300 305 308 980 410 319 915 341 946 355 345 360 366 Colombia Comoros Congo Cook Islands Corsica Costa Rica Croatia Cuba Curacao Cyprus Cyprus (Greek) Cyprus (Turkish) Czech Republic Czechoslovakia Denmark Djibouti Dominica Dominican Republic Dutch East Indies East Germany Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia 367 140 368 374 396 398 399 145 397 402 406 409 412 414 418 420 422 427 055 429 435 436 438 440 451 462 473 484 Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern / Antarctic Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland SPEX Basic Service Gen Inst 11/2014 495 506 517 528 539 102 550 561 563 566 572 575 576 577 580 969 India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea 649 082 084 650 651 652 653 654 655 657 209 658 659 672 660 665 Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles 773 781 148 785 790 573 662 792 581 584 587 590 595 605 607 610 613 615 616 618 619 621 620 112 622 624 623 625 627 086 080 630 632 634 141 669 Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Madeira Islands Malawi Malaysia Maldives Mali Malta Mariana Islands Marshall Islands Martinique Mauritania Mauritius Mayotte Media 144 671 682 688 690 147 110 582 152 952 949 693 695 New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Vietnam North Yemen Northern Ireland Norway Oman Pacific Islands Trust Territory Pakistan Palestinian Authority Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Portuguese Timor Puerto Rico Qatar 794 088 704 560 715 720 726 737 748 105 759 770 771 053 772 4 793 661 306 666 395 142 798 796 797 947 820 821 822 823 496 825 663 967 826 828 830 836 150 583 151 153 953 847 220 000 848 850 Reunion Romania Ross Dependency Russia Rwanda Ryukyu Islands Saba Saint Barthelemy Saint Helena & Dependencies Saint Kitts & Nevis Saint Lucia Saint Maarten Saint Martin Saint Pierre & Miquelon Saint Vincent And The Grenadines San Marino Sao Tome & Principe Saudi Arabia Scotland Senegal Serbia Seychelles Sierra Leone Sikkim Singapore Sint Eustatius Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sandwich Islands South Vietnam South Yemen Spain Sri Lanka Stateless Sudan Suriname 855 858 869 875 244 882 880 891 893 149 892 894 895 902 903 106 904 905 908 916 917 999 924 099 913 928 930 932 935 941 054 092 948 146 411 158 795 951 957 266 965 775 Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Unknown Uruguay USA USSR Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands Wake Island Wales Wallis And Futuna West Germany Western Sahara Western Samoa Yemen Yugoslavia Zaire Zambia Zimbabwe SPEX Basic Service Gen Inst 11/2014 Allopathic (M.D.) Specialty Code List (Alphabetical) 01 Allergy & Immunology 02 Anesthesiology 03 Colon & Rectal Surgery 04 Dermatology 05 Emergency Medicine 06 Family Practice 07 Internal Medicine 42 Medical Genetics 08 Neurological Surgery 09 Neurology 10 Nuclear Medicine 11 Obstetrics & Gynecology 12 Ophthalmology 13 Orthopedic Surgery 14 Otolaryngology 21 Radiology 15 Pathology 22 Surgery 16 Pediatrics 23 Thoracic Surgery 17 Physical Medicine & Rehabilitatio2n4 Urology 18 Plastic Surgery 19 Preventative Medicine 20 Psychiatry Osteopathic (D.O.) Specialty Code List (Alphabetical) 43 Allergy & Immunology 25 Anesthesiology 26 Dermatology 27 Emergency Medicine 44 Family Medicine 28 General Practice 29 Internal Medicine 30 Neurology & Psychiatry 31 Nuclear Medicine 32 Obstetrics & Gynecology 5 33 Ophthalmology & Otorhinolaryngology 34 Orthopedic Surgery 35 Pathology 36 Pediatrics 37 Preventative Medicine 38 Proctology 39 Radiology 40 Rehabilitation Medicine 41 Surgery SPEX Basic Service Gen Inst 11/2014 Special Purpose EXamination (SPEX)® Application for SPEX Part A. - To be completed by applicant. Refer to the Application Instructions when completing this form. Complete all pages and print in ink or type. 1. Name Print your name exactly as it appears on the unexpired, government-issued identification you plan to present at the test center. Last (Surname) and suffix First and Middle names If you have applied previously under another name for any examination listed in section 7 of this form, please provide that name. Reason for Change: If you have not notified us previously of your name change and want your name changed on the official SPEX record, you must provide a copy of legal documentation that verifies this change. 2. Date of Bir th Abbreviate months as: JAN, FEB, MAR, APR, MAY, JUN, JUL, AUG, SEP, OCT, NOV, DEC. 3. U.S. Social Securi ty and Nati onal Ide nt ifi ca ti on N umber s Enter your SS number and/or the official number assigned by your country if outside the U.S. See instructions for country codes. Month Day Year U.S. Social Security Number National Identification Number 4. Gender Male 5. Citizenship upon entering Medical School See instructions for country codes. Country Code Country Code Name of Country Female Name of Country Medical School of Graduation 6. Medical Educati on See instructions for country codes. G radu at i on Date: Abbreviate months as: JAN, FEB, MAR, APR, MAY, JUN, JUL, AUG, SEP, OCT, NOV, DEC. Country Code Graduation Date Month Degree: 7. Examination History and Ide nt ifi ca ti on N umber Indicate all the examinations that you have taken. Country of Medical School M.D. Year D.O. Other (specify) Exam ination Identification Number (if known) FLEX FLEX USMLE Step 1, Step 2, or Step 3 USMLE NBME Part I, Part II, or Part III NBME ECFMG FMGEMS/NBME Part I or Part II/VQE ECFMG SPEX SPEX Specialty of current practice 8. Speci al ty See instructions for specialty codes. Are you certified in this specialty by an ABMS or AOA-BOS -approved board? Yes No Are you certified in another specialty by an ABMS or AOA-BOS -approved board? Yes No If yes, give code(s) of other specialty(ies) Page 1 a. b. c. 9. Li cens e (s ) hel d See instructions for state board codes. You must provide a photocopy of your medical license. License Number Board Code License Number Board Code License Number Board Code 10. Addr ess This address will be used for correspondence regarding registration for SPEX. Print your current mailing address. Address Line 1 If you provide an address outside the U.S., correspondence relating to SPEX may be significantly delayed. Provide a U.S. address, if possible. Address Line 3 If your address changes or is different for score reporting, see Instructions, “Address Changes.” See Instructions for Country Code. Address Line 2 City State/Province Country Country Code Code ZIP/Postal ( ) Daytime Telephone Number 11. Test Accommodati ons 12. S i gnat u re Review the SPEX Information Bulletin before signing this statement. E-mail address I have a documented disability covered under the American with Disabilities Act and am requesting test accommodations. (Checking this box does not constitute an official request. You must submit your request for test accommodations and accompanying documentation at the same time as this application. See Instructions, “Testing Accommodations.”) I certify that I currently meet the SPEX eligibility requirements, that the information provided on this form is true and accurate. I also certify that I have read the current SPEX Information Bulletin and the application instructions, that I am familiar with their contents, and agree to abide by the policies and procedures described therein. I understand that I may be required to verify my eligibility for this examination, and I agree to pay any related fees. Applicant Signature Date Provision of the following information is voluntary. The information will be used for research purposes only. You are encouraged to provide the information.The processing of your application will not be affected by your choice in this regard. Select the option which best describes your race/ethnicity Is English your native language? 1 2 American Indian/ Alaskan Native 3 Asian Yes 5 4 Native Hawaiian or other Pacific Islander Hispanic or Latino Black or African American 6 White No Part B. — To be completed by Medical Licensing Authority 1. Lice ns in g Au th or ity for which SPEX is being taken. 2. State Board Contact 3. Licensure Histor y 4. Examinee’s Purpose for taking SPEX. Page 2 Name of Licensing Authority Board Code Name of contact Title Signature Date Does applicant currently hold an unrestricted license in any U.S. jurisdiction? License by endorsement Yes License number No Board Code Required as part of a disciplinary process License number Board Code Reactivation of an inactive license License number Board Code 7 Other Securely affix in this square a current front-view, 2” x 2” photograph of head and shoulders, which should approximately fill the space. (Print full name on back of photograph before attaching.) Special Purpose Examination Identification Card Name (Please print or type) Last Date of Birth: _______ Month First Day Gender: Year Middle Initial Male Female Certification of Identification Certification by Notary Public or Commissioner of Oaths is required. SEAL The impression of the seal must be partly upon the photograph and partly upon the signature of the applicant Applicant Signature By my signature above, I certify that all of the information provided on this form is true and accurate. Page 3 State of County of I certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this applicant by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the applicant with the photograph affixed hereto and (b) comparing the applicant’s signature made in my presence on this form with the signature on his/her identifying document. The statements in this document are subscribed and sworn to before me by the applicant on this day of , . Day Notary Public Signature Month Year
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