Department of Paediatrics

DEPARTMENT OF PAEDIATRICS

THE HOSPITAL FOR SICK CHILDREN

UNIVERSITY OF TORONTO

APPLICATION FOR POSTGRADUATE RESIDENCY OR FELLOWSHIP TRAINING

SELECT POSITION APPLYING FOR:

Pediatric Emergency Medicine Fellowship

Academic Fellowship (RCPSC Accredited): 2-3 year program

Clinical Departmental Fellowship: 1 year program

Training dates requested:

fromto

day/month/yearday/month/year

If you are an international candidate, are you sponsored/funded by your home institution?

Yes______No______

Name:

SurnameFirstMiddle

Current Mailing Address:

Permanent Address:

(if different from above)

Social Insurance Number (Canadian)

Telephone Numbers:Home:()

Work:()

FAX:()

E-mail address:

SKYPE ID: ______

CITIZENSHIP STATUS: (please circle one)

A.CanadianCitizen

B.Landed Immigrant (Please enclose a copy of your landed immigrant status).

C.Is a Work Permit Visa required? If so please provide:

Date of Birth (m/d/y) (required for visa)

Please indicate the location of the Canadian Immigration Office nearest

you. This information is available from any Canadian Consulate or Embassy:

LICENSING:

Are you currently licensed to practice medicine in the Province of Ontario? YES NO

If yes:Independent practice license numberexpiry date

OROntario postgraduate certificate of registration number

expiry date

Have you ever been subject to any disciplinary action or license suspension by any licensing authority? If so, please provide details in an accompanying letter.

LANGUAGES and QUALIFYING EXAM:

The following section must be completed by graduates of medical schools outside Canada and

the USA:

Native language spoken

Language of instruction at medical school

Other languages spoken

Please indicate whether you have passed the following examinations. (If so, please provide proof of success at these exams.)

MCCEE (Medical Council of Canada Evaluating Exam)YES NO

TOEFL (Test of English as a Foreign Language)Score

TSE (Test of Spoken English)Score

EDUCATION AND TRAINING:

a)MedicalSchool:

Institution and LocationYear of GraduationDegree earned

b)Internship:

Institution and LocationType of InternshipStart & end dates

c)Postgraduate Residency and Fellowship Training:

PositionInstitution and LocationStart & end dates

d)Specialty Certification:

TypeDate Received

REFERENCES:

Please ask three referees to send letters directly to us, and listtheir names, titles and positions below.

One of these must be from your program director.

Please give name, address, telephone number, and relationship of an individual to be contacted in case of emergency:

I certify that the information provided in this application is correct and complete, to the best of

my knowledge.

Signature of ApplicantDate

Please enclose the following documents with the completed application form:

1)Current curriculum vitae

2)Photocopy of medical degree

3)Photocopy of your PaediatricSpecialty Certificate

4)MCCEE pass letter (if applicable)

5)TOEFL and TSE results (if applicable)

6)Proof of landed immigrant status (if applicable)

7)Three (3) Reference Letters

8)Two passport size photos

Applications for subspecialty training/fellowshipshould be sent directly to the program:

Ms.Catherine Wong

Paediatric Emergency Medicine Fellowship Program

The Hospital for Sick Children

555 University Avenue

Toronto, Ontario

M5G 1X8 Canada

Email:

Rev. August 20133