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PERSONAL DATASurname Student Number (University of Ottawa)Given names
Mailing address
Number and street
City Province / Country
Apartment
Postal code
Area code and telephone number At workAt home
Sex Male Female Date of birth Social Insurance Number
Mother tongue OtherFrench English Language of correspondence French English
Country of birth : Country of citizenship :
If non-canadian, indicate date of arrival into Canada
If non-Canadian, specify your current status
Permanent Resident
Other (specify)
Work PermitStudent Authorization (Student Visa)
Diplomatic Visa
(Please print)
ACADEMIC DATA*
PREMEDICAL
MEDICAL
INSTITUTION LOCATION DEGREE YEAR
- You may also attach a résumé. Please arrange for your previous medical schools to forward your transcripts to the director of the program concerned.*
PROGRAM REQUESTEDSPECIALTY SUBSPECIALTY
Residency level requested :
Clinical Fellowship Type Research Fellowship Type
(Specify)
Year DayMonth
Year Month
................ ......
APPLICATION FOR POSTGRADUATE MEDICAL TRAINING
Cellular
Type requested Type requested
Area of focused competence (AFC) : Accreditation without certification (AWC) :
(Specify)
POSTGRADUATE TRAINING COMPLETED
EXAMS AND LICENCE
REFERENCES
TOFROMLOCATIONPROGRAM AND UNIVERSITY
1 st year
2 nd year
3 rd year
4 th year
5 th year
Have you had your training thus far assessed by the Royal College or the College of Family Physicians of Canada? YesNo If so, please attach a photocopy of the report.
Have you taken and successfully passed
A qualifying exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Test of Spoken English (TSE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Test of English as a Foreign Language (TOEFL) . . . . . . . . . . . . . . . . .
The Medical Council of Canada evaluating exam . . . . . . . . . . . . . . . . . . . .
YesNo
YesNo
YesNo
YesNo
No. :
Score :
Score :
No. :
YesNo No. :Are you licenced to practice medicine in Ontario? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Give the names of three (3) doctors who have participated in your training and who have been asked to send letters of reference. It is the applicant 's responsability to ensure that letters of reference are sent directly to the Director of the program concerned.
(N.B.: If this is a recognized program, one of the references must be the Program Director.)
1Area code and telephone numberName Title
3Area code and telephone numberName Title
2Area code and telephone numberName Title
I certify that the above information is true and complete, including my declaration of citizenship and status in Canada. Any false declaration on my part will result in the cancellation of my admission / registration. If appointed, I agree to abide by all regulations of the University of Ottawa and the hospital(s) in which my training will take place.
MEDE-5096(E) PDF 2013/09
Date Signature of the applicant
6 th year
7 th year
8 th year
Other training / experience / publication(s)
The National Assessment Collaboration exam (NAC) . . . . . . . . . . . . . . . . . YesNo Score :
RESIDENCY LEVEL
