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

• Last Name
• First Name(s)
• ECFMG Number
• Check one:
  • Initial Application
  • Request for Extension - Specify reason for extension
  • Change of Field of Practice**
  • Other - Specify
    
• Date(s) of previous applications)
• Current Mailing Addresses in Canada and the United States (if known)
• Permanent Address in Canada
• Work Number
• Home
• Pager
• Facsimile
• E-Mail
• Country of Citizenship
• Name & Country of Medical School
• Year Awarded

Completed Postgraduate Medical Specialty Training :

• University
• Dates
• Specialty

Proposed Training:

• Name of Fellowship (provide the precise wording to appear on your Statement of Need)
• (**)If this is change in field of practice: Name of Specialty
• 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:

• I intend to return to Canada upon completion of my postgraduate medical specialty training in the United States to 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 Canadian licensure or certification bodies.
• I acknowledge that it is my responsibility to fully meet and/or maintain all Canadian medical licensure and certification requirements in order to practise medicine in the field for which I will have received training in the United States, and I agree to take any necessary steps to maintain my full 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 purpose of the "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 ( ) / 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

Please remember to submit both pages of this form.