PGME Visiting Electives Application Form - Postgraduate Medical Education

LEARNER INFORMATION

Full Legal Name (First, middle name if given, Last) *

Date of Birth *

Citizenship *

Gender

Residency School *

Residency/Training Program *

Home Student # *

CPSO #

CMPA #

MINC #

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

Level of Learner at time of Elective *

Funding Source *

Learner Address line 1 *

Learner Address line 2

Email *

Phone Number

ROTATION INFORMATION

Rotation Specialty *

Start Date *

*PLEASE NOTE, APPLICATIONS MUST BE SUBMITTED 8 WEEKS IN ADVANCE OF START TO BE CONSIDERED*

End Date *

Rotation Location *

Hamilton Health Sciences (HHS)
St. Joseph's Hospital
Other

Have you worked with EPIC before? *

Yes
No
Unsure

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Have you ever withdrawn or been required to withdraw from any postgraduate medical training?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

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:

Please attach the following documents

If unavailable at this time, please email to pgmeve@mcmaster.ca as soon as possible

Proof of current mask fit test *

Click or drag a file to this area to upload.

Letter of support from your Program Director *

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.

Out of Province Applicant Requirements:

CPSO application to be submitted directly to CPSO (at least 6 to 8 weeks prior to elective start date) https://www.cpso.on.ca/Registering-to-Practise-Medicine-in-Ontario/Registration-Applications-and-Forms

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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