Application Form for a Statement of Need From the Government of Canada for Medical Graduates Seeking Postgraduate Training in the United States - Category A - Final Year Medical Student (FYMS) - Ontario, British Columbia and Quebec

• Last Name
• First Name(s)
• ECFMG Number
• Check one:
  • Initial Application for Specialty
  • Request for Change of Specialty
  • Request for Change of Location of Residency Program (same specialty)
  • Request for Extension ( ) Fellowship ( ) Sub-Specialty - Specify reason for extension
• Date(s) of previous application(s)
• 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 U.S.:

• Name of Specialty / Sub-Specialty / Fellowship (wording will appear on your Statement of Need)
• Start Date of U.S. Training
• Duration
• Name of U.S. Program Director
• Full Name, Address, Telephone No., Facsimile No. of University and Hospital in the United States

I hereby state with sincerity that:

1. All applicants (Please Read Before Signing)

• I intend to return to Canada to practice medicine on completion of postgraduate training in the United States and I intend to enter the practice of ____ in Canada upon completion of my postgraduate medical training in the United States.
• I acknowledge that it is my responsibility to fully meet all Canadian certification and medical licensure requirements for my specialty and/or subspecialty in the province or territory of ____ in order to practise medicine in that province or territory.
• I understand that receipt of a Statement of Need from the Government of Canada does not constitute a guarantee of employment including employment in my specialty.
• I have read and I understand the purpose of the"Consent to the Disclosure of Personal Information to Provincial and Territorial Governments for Recruitment Purposes" and 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.

2. Applicants seeking a standard full Canadian licence (Please Read Before Signing)

Royal College of Physicians and Surgeons of Canada (RCPSC) Certification

• I understand that the medical specialty training in the United States may not fully meet the RCPSC's Specialty Training Requirements in the specialty / subspecialty of ____ and therefore it is my responsibility to obtain and complete all additional training required to become eligible for certification by the RCPSC.
• I agree to take the necessary steps to obtain certification by the RCPSC in the specialty / subspecialty of ____ including Preliminary Assessment of my training by the end of April of the final year of my residency and subsequently passing the RCPSC examination.

Licentiate of the Medical Council of Canada (LMCC)

• I agree to pass all MCC examinations by the end of my third year of postgraduate medical training in the United States and be enrolled on the Canadian Medical Register as a Licentiate of the Medical Council of Canada.

3. Applicants seeking a medical licence in British Columbia or Ontario via an alternate pathway (Please Read Before Signing)

I agree to meet all medical licensure requirements for the specialty / subspecialty of ____ in the province of____ in order to practise medicine in that province,including:

• (1.a) passing all MCC examinations by the end of my third year of postgraduate medical training in the United States and be enrolled on the Canadian Medical Register as a Licentiate of the Medical Council of Canada,
  
  OR
  
• (1.b) passing the USMLE Steps 1, 2 and 3 by the end of my third year of postgraduate medical training in the United States,
  
  AND
• (2.a) taking all necessarysteps to obtain certification by the RCPSC in the specialty / subspecialty of____ including Preliminary Assessment of my training by end of April of the final year of my residency and subsequently passing the RCPSC examination,
  
  OR
• (2.b) taking all necessary steps to meet the RCPSC Specialty Training Requirements in the specialty / subspecialty of____ including Preliminary Assessment of my training and subsequently passing the RCPSC examination within the timeframe set out in CPSBC By-Laws,
  
  OR
• (2.c) taking all necessary steps to become a Diplomat of the American Board for my specialty / subspecialty upon completion of my postgraduate training in the United States and obtaining a restricted medical licence in Ontario using a CPSO-approved alternate pathway

Signatures of Applicant and Witness

• Print Name of Applicant
• Signature of Applicant
• Date

This Consent is Signed in the Presence of:

• Print Name of Witness
• Signature of Witness
• Date