Application Form for a Statement of Need From the Government of Canada for Medical Graduates Seeking Postgraduate Training in the United States - Category A

• Last Name
• First Name(s)
• ECFMG Number
• Check one:
  • Fellowship (Professional Development)
  • Extension of Fellowship - Specify Reason
  • Short Term Elective or Rotation
  • Other - Specify
• Date(s) of previous application(s), if any
• Current Mailing Addresses in Canada and the U.S. (If available)
• Permanent Address in Canada (required)
• Work Number
• Home
• Pager
• Facsimile
• E-Mail
• Country of Citizenship
• Name of Medical School
• Year Degree Awarded

Completed and Current Postgraduate Medical Specialty Training:

• University/Hospital
• Dates
• Specialty

Proposed Training in the United States:

• Name of Fellowship. [This wording will appear on your Statement of Need]
• Name of Short-Term Elective/Rotation
• Start Date
• Duration
• Name of Program Director in the United States
• Full Name, Address, Telephone No., Facsimile No. of University and Hospital in the United States

I Hereby State With Sincerity That:

• I intend to return to Canada on completion of my postgraduate medical specialty training in the United States.
• On my return to Canada, I intend to enter the practice of medicine in the medical specialty for which I will have received training.
• I understand that the medical specialty training that I will receive in the United States may not meet the specifications of the Royal College of Physicians and Surgeons of Canada.
• I acknowledge that it is my responsibility to fully meet all Canadian medical licensure and certification requirements in order to practise medicine in Canada and to take all necessary steps to obtain and/or maintain licensure and certification in Canada.
• I understand that receipt of a Statement of Need from the Government of Canada does not constitute a guarantee of employment including employment in the practice of medicine in the specialty for which I will have received training.
• I have read and I understand the form "Consent to the Disclosure of Personal Information to Provincial and Territorial Governments for Recruitment Purposes" and I have / have not signed the form.
• I understand that Health Canada releases some personal information about Statement of Need recipients to The Canadian Post-M.D. Education Registry (CAPER) on an annual basis for the purpose of research on physician resources and I agree / I disagree to the release of information to CAPER for this purpose.

Signatures of Applicant and Witness

• Print Name of Applicant
• Signature of Applicant
• Date

This Application and Consent is Signed in the Presence of:

• Print Name of Witness
• Signature of Witness
• Date

Please remember to submit both pages of this form.