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Applications and Forms
PGME Visiting Electives Application Form
PGME Visiting Electives Application Form
Please enable JavaScript in your browser to complete this form.
LEARNER INFORMATION
Full Legal Name (First, middle name if given, Last)
*
Date of Birth
*
Citizenship
*
Gender
Male
Female
Other
Residency School
*
Residency/Training Program
*
Home Student #
*
CPSO #
CMPA #
MINC #
About MINC - https://mcc.ca/examinations/minc/
Level of Learner at time of Elective
*
PGY-1
PGY-2
PGY-3
PGY-4
PGY-5
PGY-6
PGY-7
Clinical Fellow
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
Do you want to test out?
*
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Have you ever withdrawn or been required to withdraw from any postgraduate medical training?
*
Yes
No
If yes, please explain:
Have you ever been disciplined by a university or medical authority?
Yes
No
If yes, please explain:
Have you ever had your medical license suspended or revoked in any jurisdiction?
Yes
No
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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