Application Form for a Statement of Need from Health Canada for Medical Graduates Seeking Postgraduate Training in the United States
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Warning: Any false or misleading statement with respect to this application and any supporting document, including the concealment of any material fact, may result in the refusal to issue a Statement of Need. Your application will not be processed if you fail to complete all of the sections of this form, including submission of supporting documents, and/or refuse to consent to the exchange or disclosure of any personal information required for the delivery of Statement of Need to the Educational Commission for Foreign Medical Graduates in the United States.
Type or print in CAPITAL LETTERS using black or dark blue ink.
View Instructions for Completing a Statement of Need Application prior to completing this form.
Is this your first application?
Date(s) of previous application(s)
Under which category are you applying?
Part A: Personal Information
(Applicants must provide a notarized copy of one of the following (see instructions for details):
Permanent Resident of Canada
Permanent Address in Canada
Mailing Address (in Canada or United States)
Part B: Medical School and Postgraduate Medical Training
Name of Medical School or School of Osteopathic Medicine Year of Graduation
Name of training institution
Part C: Competed Postgraduate training – Canada and/or the United States
Subspecialty / Fellowship
Name of training institution
Part D: Proposed Postgraduate Training in the United States
Field Of Training:
Start date Duration
Name and mailing address of training institution
Part E: Agreement to Return to Canada to Practice Medicine
I Hereby State With Sincerity That:
- I intend to return to Canada upon completion of my postgraduate medical specialty training in the United States to practice of medicine in the medical specialty for which I will have received training.
- On my return to Canada, I intend to enter the practice of ________.
- I understand that it is my responsibility to be informed of the requirements of medical licensure and certification requirements in Canada.
- I understand that the medical specialty training I will receive in the United States may not meet the specifications of Canadian licensure or certification bodies and I agree to take any necessary steps to meet Canadian medical licensure and certification requirements.
- I understand that receipt of a Statement of Need from the Government of Canada does not constitute a guarantee of employment including employment in the practice of medicine in the specialty for which I will have received training.
- I understand that Health Canada releases some personal information about Statement of Need recipients to The Canadian Post-M.D. Education Registry (CAPER) on an annual basis for the purpose of research on physician resources and I agree / I disagree to the release of information to CAPER for this purpose.
- I have read and I understand the purpose of the "Consent to the Disclosure of Personal Information to Provincial and Territorial Governments for Recruitment Purposes" and I have / have not signed the form.
Part F: Supporting Documents (See instructions for Completing a Statement of Need Application for details)
Submit the following document with your applications form:
- Proof of Canadian Citizenship or Permanent Residency (Notarized copy)
- Proof of Training: submit one of the following: 1) US Match Page 2) Contract or 3) Letter of Offer
- Disclosure of Personal Information for Recruitment (Optional)
Part G: Signatures of Both Applicant and Witness
APPLICANT Declaration – I solemnly declare that I am a Canadian citizen or Permanent Resident of Canada and that the information contained in this application and supporting documents, are true. I declare that I have read and understood the Warning at the top of the application form and statements outlined under section E. I consent to the collection, use and disclosure of my personal information by the Statement of Need Program to the Educational Commission for Foreign Medical Graduates in the United States.
Name of Applicant Signature of Applicant Date
WITNESS Declaration – I solemnly declare that I have read and understood the Warning at the top of this application and that the information within this application, is true.
Name of Witness Signature of Witness Date
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