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

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• Last Name
• First Name(s)
• ECFMG Number
• Check One:
  • Initial Application
  • Request for Extension for Fellowship
    • Name of Fellowship
• Current Mailing Address:
• Permanent Address in Canada (required)
• Address in the United States, if known
• Telephone Number
  • Home
  • Work
  • Pager
• Facsimile
• E-Mail
• Country of Citizenship
• Name and Country of Medical School
• Year Obtained

Completed & current postgraduate training outside Canada / United States

• University/Country
• Dates
• Specialty

Proposed training in the United States

• Start Date of 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 in Family Medicine, and I intend to enter the practice of Family Medicine in Canada upon completion of my postgraduate training in the United States.
• I acknowledge that it is my responsibility to fully meet all Canadian certification and medical licensure requirements for Family Medicine 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 Family Medicine.
• 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. All applicants seeking a Canadian standard medical licence (unrestricted)

• I agree to meet all medical licensure requirements for Family Medicine in the province or territory of ( ) in order to practise medicine in that province or territory, including:

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 U.S. and be enrolled on the Canadian Medical Register as a Licentiate of the Medical Council of Canada.
  
  AND

Certificant of the College of Family Medicine (CCFP)

• (2.a) passing the Family Medicine certification examination of the College of Family Physicians of Canada within the last six months of postgraduate training in the United States. OR
• (2.b) taking the necessary steps to become a Diplomat of the American Board of Family Medicine and obtaining certification without examination from the College of Family Physicians of Canada upon completion of my postgraduate training in the United States.

3. Only applicants seeking a provisional medical licence in British Columbia or a restricted medical licence in Ontario, using an alternate pathway

• I agree to meet all medical licensure requirements for Family Medicine in the province of ( ) order to practise medicine in that province, including:

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 U.S. and be enrolled on
  the Canadian Medical Register as a Licentiate of the M edical Council of Canada. OR
• (1.b) passing the USMLE Step 3 by the end of my third year of postgraduate medical training in the United States, AND

Certificant of the College of Family Medicine (CCFP)

• (2.a) p assing the Family Medicine certification examination o f the College of Family Physicians of Canada within the last six months of postgraduate training in the United States. OR
• (2.b) taking the necessary steps to become a Diplomat of the American Board of Family Medicine and obtaining certification without examination from the College of Family Physicians of Canada upon completion of my postgraduate training in the United States.

Signatures of Applicant and Witness

• Print Name of Applicant
• Signature of Applicant
• Date

This Application is Signed in the Presence of:

• Print Name of Witness
• Signature of Witness
• Date