McMaster University

McMaster University

MDCL in the evening

Postgraduate Medical Education Visiting Electives Application Form

Please note that all fields are required.

LEARNER INFORMATION

Learner Legal Last Name
Learner Legal First Name
Date of Birth
Citizenship
Gender Male    Female   Other:
Residency School
Home Student #
CPSO#
CMPA#
MINC#
About MINC
Level of Learner
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
Learner Email
Learner Home Phone
Learner Mobile Phone

ROTATION INFORMATION

Rotation Specialty
Rotation Start Date
Rotation End Date

Rotation Site

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

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Have you ever withdrawn or been required to withdraw from any postgraduate medical training?
No   Yes    If yes, please explain:
Have you ever been disciplined by a university or medical authority?
No   Yes    If yes, please explain:
Have you ever had your medical license suspended or revoked in any jurisdiction?
No   Yes    If yes, please explain:
Additional documents to be submitted upon completing this application:
Proof of current mask fit test
Letter of support from your program director
Letter from McMaster program director/supervisor

Please submit the above supporting documentation to Dana Gordon in the PG office by fax (905-527-2707) or email dgordon@mcmaster.ca

Out of Province Applicant Requirements:

CPSO application to be submitted directly to CPSO (at least 6 to 8 weeks prior to elective start date)

Complete the PG McMaster Health Screen Record and submit to McMaster University Health Screening Office at least 8 weeks prior to your start date to allow for processing and clearance. Health Screen Record and instructions for submission may be found on the FHS Health Screening website.

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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