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FACULTY OF HEALTH SCIENCES

PGME Fellowship Application Form

Reminder, if you are gulf sponsored, please apply directly through your sponsoring agency.

Learner Information

McMaster University Postgraduate Medical Education does not fund fellows and will not except or consider applications unless a funding source has been identified for salary support.

Name *

First

Last

Have you secured funding? *

Date of Birth *

Citizenship *

Please indicate if you hold citizenship and what passport you would be entering Canada on.

Place of Birth *

That the purpose of these questions is to facilitate immigration paperwork should the applicant receive a fellowship offer.

If you hold dual citizenship what passport will you enter Canada on?

Gender

Email - please do not use a yahoo email address *

Learner Address line 1 *

Learner Address line 2

Phone Number

CPSO #

If you currently have, or previously had a CPSO license, please list it.

CMPA #

If you currently have, or previously had a CMPA membership, please list it.

MINC #

About MINC - https://mcc.ca/examinations/minc/

Fellowship program you are applying to: *

Year of Fellowship program you are applying to: *

Medical Education

Medical School *

Address *

Degree Granted *

Year Granted *

Have you ever withdrawn or been required to withdraw from any postgraduate medical training?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

If yes, please explain:

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

If yes, please explain:

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

If yes, please explain:

Have you ever been enrolled in a Pre-Entry Assessment Program within Ontario? *

Yes
No

The following documents must be submitted with your application. Translations must be provided with the application and official documentation, relating to qualifications, both undergraduate and postgraduate.

These documents must be uploaded and submitted in PDF format.

Personal Statement *

Click or drag a file to this area to upload.

2 pages maximum

Up-to-date CV (must be up-to-date within 6 months of application submission) *

Click or drag a file to this area to upload.

Medical Degree *

Click or drag a file to this area to upload.

Please note: If the name on your medical degree does not match the name on your passport or government issued identification, then you must provide legal documentation or a letter from your medical school, confirming that the name of the person on the medical degree is in fact the same person listed on your legal identification.

Specialty Certificate (or MCCQE1 exam results if no specialty certificate) *

Click or drag a file to this area to upload.

Please note: If the name on your specialty certificate does not match the name on your passport or government issued identification, then you must provide legal documentation or a letter from your medical school, confirming that the name of the person on the specialty certificate is in fact the same person listed on your legal identification.

Undergraduate Medical School Transcript 1 - Medical school transcripts that are encrypted or have other securities must be scanned to a printer and uploaded as a PDF to the application. Transcripts with these securities will not allow us to download and save them. *

Click or drag a file to this area to upload.

Please note: If the name on your transcripts does not match the name on your passport or government issued identification, then you must provide legal documentation or a letter from your medical school, confirming that the name of the person on the transcripts is in fact the same person listed on your legal identification.

Undergraduate Medical School Transcript 2

Click or drag a file to this area to upload.

Please note: If the name on your transcripts does not match the name on your passport or government issued identification, then you must provide legal documentation or a letter from your medical school, confirming that the name of the person on the transcripts is in fact the same person listed on your legal identification.

Undergraduate Medical School Transcript 3

Click or drag a file to this area to upload.

Please note: If the name on your transcripts does not match the name on your passport or government issued identification, then you must provide legal documentation or a letter from your medical school, confirming that the name of the person on the transcripts is in fact the same person listed on your legal identification.

Reference Letter 1 *

Click or drag a file to this area to upload.

Maximum file size for each PDF is 5MB

Reference Letter 2 *

Click or drag a file to this area to upload.

Maximum file size for each PDF is 5MB

Reference Letter 3 or Medical School Letter *

Click or drag a file to this area to upload.

Maximum file size for each PDF is 5MB

Reference Letter 4

Click or drag a file to this area to upload.

Maximum file size for each PDF is 5MB

Canadian Government issued photo ID / Copy of passport you will enter Canada with *

Click or drag a file to this area to upload.

Maximum file size for each PDF is 5MB

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.

Phone