Application Form for a Statement of Need from Health Canada for Medical Graduates Seeking Postgraduate Training in the United States

(PDF Version - 662 K)

Is this your first application?

• Yes
• No

Date(s) of previous application(s)

Part A: Personal Information

First Name(s)
Last Name

• F
• M

ECFMG Number
(Applicants must provide a notarized copy of one of the following (see instructions for details):
Canadian Citizen
Permanent Resident of Canada

Telephone Number(s)

Email(s)

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

Specialty
Name of training institution
Dates

Part C:  Competed Postgraduate training – Canada and/or the United States

Subspecialty / Fellowship
Name of training institution
Dates

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