UNIVERSITY OF CALGARY

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					UNIVERSITY OF CALGARY
DEPARTMENT OF FAMILY MEDICINE
Application for PGY3 Enhanced Skills Training

APPLICANT INFORMATION

Last Name:                                              First Name:                                    M.I.:          Date:

Street
                                                                                                       Apartment/Unit #:
Address:

City:                                                      Prov:                                       Postal Code:

Phone:                                                     E-mail Address:

                                                                                                Date of Birth
Fax:                                                       SIN #:
                                                                                                (yyyy/mm/dd)

College of Physicians & Surgeons License #:

Canadian Medical Protective Association (CMPA) #:

Medical School and Year of Graduation:

Are you a citizen of Canada?                   YES         NO

If not a Canadian Citizen, please complete:

   Landed Immigrant/Permanent Resident               Working Visa                                    Certified Refugee

   Other, please explain:

ARE YOU A:

Resident                 Resident (PGY) Level:                      Department/Division:

Residency Program & Site:

Program Coordinator/Administrator Name:

Phone:                                                                      Fax:

Do you currently hold an educational license in the province of Alberta?       YES         NO

If not licensed in Alberta, are you eligible to be appointed as a
                                                                               YES         NO
postgraduate trainee to the educational register in Alberta?
                                                                         OR

Practicing Family Physician (re-entry status)

Practice Address (if different from above):

Phone (Daytime):                                                            Fax:

Do you currently hold a full license to practice in the province of
                                                                                   YES     NO
Alberta?
If not licensed in Alberta, are you eligible to obtain licensure
                                                                                   YES     NO
(educational or full) in Alberta?



                                                                                                                      PLEASE TURN OVER   
     ADDITIONAL INFORMATION
     Have you ever been the subject of any type of investigation, inquiry or proceeding by a medical licensing
     authority relating to your professional conduct, competence, capacity, or any other aspect of your medical         YES             NO
     practice?

     Have you ever had a medical license revoked, suspended, restricted, limited, or subjected to any other
                                                                                                                        YES             NO
     adverse action?


     Has there ever been any civil proceeding, legal action, insurance or other claim that was in any way related
                                                                                                                        YES             NO
     to your practice of medicine or your professional activities?


     Have you ever been denied privileges or been denied appointment or reappointment to the medical staff of
                                                                                                                        YES             NO
     a hospital or other health facility?

     REQUESTED TRAINING AREA(S) (see website for program descriptions: www.ucalgary.ca/familymedicine/R3)

        Global Health                                     Research                                    Palliative Care

         Addiction Medicine                               Sport & Exercise Medicine

         Design Your Own (please specify):

     APPLICATION REQUIREMENTS

     Please attach or forward the following standard expectations for application

          1)   Curriculum Vitae

          2)   Letter of Intent (*not applicable to Global Health)
                    Your letter of intent must reflect the criteria of the specific R3 program to which you are applying. Please review these
                    program-specific criteria available on our website (www.ucalgary.ca/familymedicine/R3) under each program heading.
     REFERENCES
     The Department of Family Medicine will contact your referees directly.

     Please indicate the name and contact information of 3 referees (one of whom must be your current Program Director if you are an R2). If
     you are a re-entry candidate, please include at least one referee who is a colleague in a health care profession who is knowledgeable about
     your work and interest in the enhanced skills area.

     Ref. 1    Name:                                                  Address:

               Phone:                              Fax:                                   Email:

     Ref. 2    Name:                                                  Address:

               Phone:                              Fax:                                   Email:

     Ref. 3    Name:                                                  Address:

               Phone:                              Fax:                                   Email:

     DISCLAIMER AND SIGNATURE

     I certify that the information recorded herein is complete and accurate to the best of my knowledge. I recognize that any misrepresentation
     or omission on my own part may cause me to be disqualified from continuing in a training program, if accepted on the basis of this
     information. I am aware of no reason why this application would not be eligible for consideration.


     Signature:                                                                                         Date:


___________________________________________________________________________________________________________________________
                          Please return this application and supporting documents to: Enhanced Skills Program,
        Department of Family Medicine, University of Calgary, Sheldon Chumir Health Centre, 8th Floor, 1213-4th St. SW, Calgary, AB, T2R 0X7
                                                               Phone: 403-955-9366
                                                               Fax: 403-476-8765

				
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