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

• Last Name
• First Name(s)
• ECFMG Number
  • Check one:
    Initial Application for Specialty
    Request for Change of Specialty
    Request for Extension ( ) Fellowship ( ) Sub-Specialty - Specify reason for extension
• Date(s) of previous applications)
• Current Mailing Addresses in Canada and the United States (If available)
• Permanent Address in Canada (required)
• Work Number
• Home
• Pager
• Facsimile
• E-Mail
• Country of Citizenship
• Name & Country of Medical School
• Year of Graduation

Completed and Current Postgraduate Medical Specialty Training :

• University/Country
• Dates
• Specialty

Proposed Training in the United States:

• Name of Specialty / Sub-Specialty / Fellowship (precise wording that will appear on your Statement of Need)
• Start Date of Training in the U.S.
• Duration
• Name of Program Director in the U.S.
• 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 U.S. and I intend to enter the practice of ____ in Canada upon completion of my postgraduate medical training in the U.S.
• 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.

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