Fellowship Application

Attachment ChecklistTo be completed by the FellowWith your application, please include all (applicable) documents listed below, in the order they appear☐ Department of Psychiatry Fellowship Application Form (all sections completed, all signatures obtained on pages 6, 7 and 8). Please send this form to the fellowship coordinator as a Microsoft Word Document via email. Required signature pages may be sent as scanned jpeg or PDF files, or sent via postal mail.☐ PGME Educational Objectives form (for Clinical Fellowship applications only. Must be completed by the supervisor.)☐ Copy of your current Curriculum Vitae (CV) which must include the following information:

trainee’s date of birth, country of birth, residential address (on page one) current employment

☐ Two (2) Letters of Reference (must be on letterhead and submitted in sealed envelopes) from the Director of a residency program, or other graduate training program. Please enter the names and contact information for your referees below:

1.2.

For M.D.’s:☐ Copy of original medical degree, in addition to English translation where applicable (translations must be from the Canadian Embassy or the Association of Translators and Interpreters of Ontario)☐ Copy of your General or Educational License☐ Copy of your Medical Council of Canada Evaluating Examination results(this does not apply to graduates of Canadian or U.S. medical schools)For All Others:☐ Copy of your Graduate Diploma☐ Appropriate License from your clinical discipline (if applicable)☐ Specialty Certificate (in Psychiatry) — copy of original specialty certification, in addition to English translation where applicable (translations must be from the Canadian Embassy or the Association of Translators and Interpreters of Ontario)*Applicable for appointees who have completed their residency training outside Canada or the U.S..☐ University of Toronto Visa Processing Fee, * This payment can be made in the form of an international money order payable to the University of Toronto in the amount of $150.00 or by credit card (VISA Card or MasterCard) by completing the Credit Card Authorization Form (applicable only for appointees who require a work permit).☐ Written confirmation of your status as a member in a good standing within your professional body☐ Salary Support Letter (proof of funding) – an official letter required as evidence that you will receive adequate funding during your Fellowship term. If you are self-funded, a personal statement and bank account balance will suffice. Please note that international medical graduates must secure funding at a minimum of $51,000 (CAD) per annum.This form must be competed and sent with all supporting documents (in the order listed above) to:

Dr. Arun Ravindran, Director, Fellowship in Psychiatry Program,c/o Fellowship OfficeDepartment of Psychiatry, Faculty of Medicine, University of Toronto – CAMH/Clarke Site250 College Street, Ste. 833, Toronto, ON M5T 1R8

Fellowship Application 2015 Page 1 of 9

Fellowship Application

Tel: 416-979-4275Email for Fellowship Coordinator: psych.fellows@utoronto.ca

Please note that the application form must be fully completed, and all required attachments, signatures, and supporting documents must be submitted as a complete packagePART 1 —Personal Information (to be completed by the candidate)Please check the applicable box:

☐Post Doctoral Fellow (PhD)☐International Medical Graduate (IMG)

☐Canadian Medical Graduate☐Non Medical (Non-MD)

First Name: Middle Name(s): Last Name:Country of Birth: Citizenship: Date of Birth (i.e. 31-Dec-84):SIN Number:

Permanent Address

Street:City:Province/State/Region: Postal Code/ZIP:Country:

Toronto Address

Street Address:City:Province/State/Region:Postal Code/ZIP:Country:☐ I do not have a Toronto address at present

Fellowship Application 2015 Page 2 of 9

Fellowship Application

Other Contact Information

Cell Phone:Home Phone:Toronto Phone Number:Primary Email Address:Secondary Email Address:

U of T Student Number: Resident Number:PART 2 — Description of Proposed FellowshipDates of Proposed Fellowship:Start Date: End Date:*Please note that the dates you provide above must match the dates on your supervisor’s support (reference) letter, and the dates on your funding letter, if applicableFellowship Activities – Please enter the projected time that will be spent in each activity (as a percentage):

Clinical: Research: Teaching:Postgraduate courses to be taken during Fellowship:☐Not ApplicableType:Institution:Psychiatry Division or Program***please note that we have reorganized our divisional structure, and moved from 14 divisions to 8. If you are unsure which division to select, please contact the program coordinator.Division:Supervisor First Name:Supervisor Last Name:

Co-Supervisor First Name:Co-Supervisor Last Name:

LocationTeaching Centre where Fellow will be located:Funding Details****Self-funded means the trainee is paying out of his/her own bank account. If the trainee is not paying out of his/her own bank account, please indicate who is paying (e.g. home university, government)Indicate the source of your funding for the duration of the fellowship:Funding Details:Funding Amount per Annum (Canadian Dollars): For International Medical Graduates, please note that the minimum funding requirement is $51,000.00 (CAD) per annum, effective immediately.Maximum number of clinical hours per week:

Fellowship Application 2015 Page 3 of 9

Fellowship Application

Educational Objectives for the Fellowship – no more than one paragraph is required. Please note that this should be developed in consultation with your intended supervisor

Summary of Proposed Fellowship - A typed summary of the proposed Fellowship, no more than two (2) pages long. Should include the following:

a) Proposed Research Program or Scholarly Activityb) Your Role/Independent Contributionc) Your Goals for the Fellowshipd) Your Career Plans

Fellowship Application 2015 Page 4 of 9

Fellowship Application

Summary of Proposed Fellowship – CONTINUED

Fellowship Application 2015 Page 5 of 9

Fellowship Application

PART 3 —Licensure, EmploymentAre you legally entitled to work in Canada (those entitled are Canadian citizens or permanent residents)?Are you licensed to practice in the province of Ontario? If “Yes” please enter the following information:General License Number:Expiry Date:Educational License Number:Expiry date:

If “No,” are you eligible to for the Educational Register in Ontario?

If “N/A,” are you registered with another Clinical Professional Body?Name of the Clinical Professional Body: Registration Number:Have you passed the Medical Council of Canada Evaluating Examination?(this does not apply to graduates of Canadian or U.S. medical schools)

If “yes” please enclose a legible copy of your results

PART 4 – Academic HistoryDegree/Diploma University/Institution Dates Attended

Current Appointment(s) Nature of Appointment Hospital/University Affiliation, Location

Part 4 — Declaration – must be completed by all applicants

Fellowship Application 2015 Page 6 of 9

Fellowship Application

1. Have you ever been convicted of a criminal offence for which a pardon has not been granted?

☐ Yes ☐ No

2. Have you ever been convicted of any other offence (for which a pardon has not been granted) that may affect your eligibility for Ontario Educational Registration?

☐ Yes ☐ No

3. Are there charges pending for an alleged offence that may affect your eligibility for Ontario Educational Registration?

☐ Yes ☐ No

IF YES to any of the above, please provide details below:Click here to enter text.

4. Have you ever been subject to a disciplinary hearing of a medical licensing authority, or a licensing authority within your discipline? IF YES, provide details below:

☐ Yes ☐ No

5. Have you ever been denied licensure by a medical licensing authority or had such licensure revoked or limited? IF YES, provide details below:

☐ Yes ☐ No

6. Have you ever been disciplined, suspended or dismissed from an undergraduate or postgraduate educational program? IF YES, provide details below:

☐ Yes ☐ No

In Submitting this application, and providing my signature below, I understand that my education and training during this Fellowship will NOT be accredited towards Royal College of Physicians and Surgeons of Canada Certification of Fellowship.I hereby certify that the information on this form and attachments is true and complete. I understand that I shall be disqualified if information is withheld or false information has been provided and that any appointment already made or begun will be cancelled and all credit revoked.As of January 2012, the College of Physicians and Surgeons of Ontario (CPSO) requires all International Medical Graduates to have their documents verified through the Physician Credentials Registry of Canada (PCRC). This process can take several weeks/months to complete. Individuals are advised to contact PCRC immediately upon notification of acceptance by PGME and the Fellowship Office. Please visit the PCRC website for details

Applicant’s Signature Date

Fellowship Application 2015 Page 7 of 9

Fellowship Application

PART 5 – Supervisor’s Statement and Approvals (must be completed by the fellowship supervisor)Description of Research, Teaching, and Clinical Activities of the Fellow:Research:

Teaching:

Clinical:

In providing my signature below, I — the supervisor — acknowledge that I have reviewed the entire application and required attachments. As such, I deem this candidate suitable for a fellowship. I will supervise him or her for the entirety of the fellowship term noted on page two (2) of this application.

Supervisor’s Signature Date

Fellowship Application 2015 Page 8 of 9

Fellowship Application

PART 6 –APPROVALSNB: Please note that all signatures must be obtained from the Department of Psychiatry in order for the application to be processed.

Fellowship Supervisor Signature Date

Hospital/Site Fellowship Coordinator/Director Signature Date

Fellowship Program Director Signature Date

Fellowship Application 2015 Page 9 of 9