International Visiting Electives Application - Postgraduate Medical Education

LEARNER INFORMATION

Name *

First

Last

Date of Birth *

Citizenship *

Gender

Email *

Phone *

Learner Address line 1 *

Learner Address line 2

Residency School *

Home School Student # *

CPSO #

CMPA #

Level of Learner *

MUST BE A PGY-3 OR HIGHER AT THE TIME OF YOUR ELECTIVE START DATE

Please attach your Funding Support Letter *

Click or drag a file to this area to upload.

This letter must be on official home school letter head from the hospital/university/agency that funds the training

ROTATION INFORMATION

Rotation Specialty *

Start Date *

End Date *

MEDICAL EDUCATION

Medical School *

Address *

Degree Granted *

Year Granted *

Language of Instruction at Medical School *

Have you ever withdrawn or been required to withdraw from any postgraduate medical training? *

Have you ever been disciplined by a university or medical authority?

Have you ever had your medical license suspended or revoked in any jurisdiction? *

Required Attachments ** Translations of documents must be provided with the application and official documentation.

The following documents must be submitted with your application. Translations of documents must be provided with the application and official documentation. These documents must be uploaded and submitted in PDF format.

Up-to-date CV *

Click or drag a file to this area to upload.

Copy of Medical Degree *

Click or drag a file to this area to upload.

Include the original and translated copy

Copy of MD Transcripts *

Click or drag a file to this area to upload.

Include the original and translated copy

Speciality Certificate or MCCEE/MCCQE1 (if taken)

Click or drag a file to this area to upload.

Copy of Passport *

Click or drag a file to this area to upload.

Home Program Letter *

Click or drag a file to this area to upload.

Letter must include elective dates, level of training, good standing, and MD school/date

Proof of current mask fit test

Click or drag a file to this area to upload.

Letter from McMaster Program Director/Supervisor

Click or drag a file to this area to upload.

By submitting this form I certify that all of the information provided in this application is true and correct. I am aware that it is an offence to make a false statement or include inaccurate information in this application.

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