Instructions for Completing a Statement of Need Application

Applicants should review these instructions before completing their application form

Part A: Personal Information

Is this your first application? If no, indicate year of initial application.

Under which category are you applying (indicate in circle)?

• Category A: Medical graduate currently enrolled in a Canadian specialty or subspecialty residency training program who wishes to pursue a fellowship.
• Category B: Final year medical student currently enrolled in any medical school, or a medical graduate of any medical school, who has not yet completed a medical specialty training program in Canada or the US who wishes to pursue medical specialty training, or a medical graduate currently enrolled in U.S. specialty or subspecialty residency training program who wishes to pursue a fellowship in the U.S.; or a licensed physician who wishes to pursue a new field of practice.
• Category C: Physician specialist licensed in Canada who wishes to pursue postgraduate training in a fellowship in the same field of practice.

Full Name: Provide your full name as indicated on your proof of Canadian Citizenship or Permanent Residency Card.

ECFMG Number: Write your ECFMG or United States Medical Licensing Examination (USMLE) number in the boxes provided. If you have a United States Medical Licensing Examination (USMLE) number, the Exchange Visitor Sponsorship Program (EVSP)/ Educational Commission for Foreign Medical Graduates (ECFMG) will use that as your numeric identifier. If you do not have a USMLE number, contact the EVSP at evsp-support@ecfmg.org to obtain your number.

Proof of Citizenship: Indicate in the circle provided if you are a Canadian Citizen or Permanent Resident of Canada. Additionally, with your application, submit a certified copy of one of the following documents:

• Canadian citizenship card
• Canadian Passport
• Record of birth in Canada
• Permanent Resident Card (non-expired)

Contact Information: Provide a telephone number and email address where you can be reached. Indicate your permanent address in Canada and the mailing address where you wish to receive a copy of your Statement of Need (if different from permanent address). If mailing address is the same as your permanent address, indicate N/A.

Part B: Medical Degree

Indicate the name of the University/School of Medicine/Osteopathic Medicine where you have completed (are currently completing) your medical degree, as well as the country and year you graduate.

Part C: Completed Postgraduate Training

Indicate any completed postgraduate training in Canada and/or the United States (provide field of medicine, name of university or hospital and year finished or anticipate finishing). If you completed a preliminary year or transitional year, include this information.

Part D: Proposed Postgraduate Training

Provide the standard wording accepted by the Exchange Visitor Sponsorship Program (EVSP). The EVSP/Educational Commission for Foreign Medical Graduates (ECFMG) requires the exact name of the training program be written on your Statement of Need. For specialties, write down the field of medicine (e.g. Internal Medicine, Family Medicine, Anesthesiology, etc.) For post residency fellowships, write down the specialty and the title of the fellowship (e.g. Anesthesiology - Pain Medicine). For non-standard fellowships, the accepted wording is usually on your letter of offer or contract; however, you should consult your ECFMG Training Program Liaison to verify you write down the accepted title of the training program.

Part E: Agreement to Return to Canada to Practice Medicine

Read and initial each section under Part E of the Application Form. Include the training you intend to practice in (on the line provided) upon return to Canada. If consenting to provincial and territorial government recruitment, include consent form for recruitment. Applicants must initial section E, sign the application form and have a witness' signature.

If you initial consent for disclosure, submit the Consent Form for Recruitment. Print the PDF form located on the Health Canada website. Read both pages of the form first, then initial page one and sign page two with a witness.

Part F: Supporting Documents

Include the following additional documents with your application form:

1) Proof of Canadian Citizenship/Permanent Residency

Submit a certified of one of the following documents (as indicated above in Section A):

• Canadian citizenship card
• Canadian Passport
• Record of birth in Canada
• Permanent Resident Card (non-expired)

Contact one of the following professionals to notarize / certify your proof of citizenship/ residency documents:

• Notary Public
• Lawyer, Attorney-at-Law
• Commissioner of Oaths
• Designated official at a Canadian Embassy or Consulate or a designated official at an American, Australian or British Embassy or Consulate or High Commission
• Medical Doctor or Dentist currently licensed in Canada
• Police officer in Canada: municipal, provincial, or federal (RCMP)
• Justice of the Peace, Judge, Magistrate or Mayor, in Canada
• Professional accountant who is a member of the Association of Practicing Accountants (APA) (United Kingdom); or one of the following professionals: Chartered Accountant (CA), Certified General Accountant (CGA), Certified Management Accountant (CMA), Public Accountant (PA), Registered Public Accountant (RPA)
• Member of Parliament (MP); Member of Provincial Parliament (MPP)(Ontario); Member of National Assembly (MNA)(Quebec); Member of House of Assembly (MHA) (Newfoundland and Labrador); Member of the Legislative Assembly (MLA)(all other provinces and territories)
• Pharmacist in Canada
• Professional Engineer in Canada
• Municipal Clerk at a City Hall in Canada
• Minister of religion in Canada

The person certifying your document cannot be a family member. Most professionals will prepare the document according to their professional practice. This person must see the original document, make a photocopy of the original document, compare the original document to the photocopy, and print the following on the photocopy: "I certify this to be a true copy of the original document".

This person must also write on the photocopy:

• the name of the original document,
• the date of certification, his or her name, and
• his or her official position or title.

This person must also sign the photocopy. Applicants should not sign anywhere on the photocopy of the document. Once certified, submit the copy in your email application submission. Documents that are unclear or illegible may cause delays in processing of application.

2) US Match Webpage / Letter of Offer /Training Contract

Provide a copy of ONE of the following:

• The secure web page National Resident Matching Program (NRMP) confirming the clinical residency training program in which you have matched in the US; or
• A letter of offer for a residency training program from the clinical training program in the US. The letter must be on the institution's letterhead and should be accompanied by your signature of acceptance of the offer; or
• A training contract for a residency training program from the clinical training program in the US. The training contract should bear your signature indicating you have accepted the offer.

Optional document:

• Consent to the Disclosure of Personal Information to Provincial and Territorial Governments for Recruitment Purposes (Optional) (See Section E of Application for Instructions) - Complete and sign the PDF version of the Consent Form for Recruitment.

Part G: Signatures of Both Applicant and Witness:

Declaration that the information within the application is accurate and support the applicant's identity and training they wish to pursue.

Witness can be any individual 18 years or older.

Submitting your application and supporting documents:

Submit all required documents by email to the Program Administrator, Health Canada. Only complete packages can be considered for a Statement of Need. It is the applicants' responsibility to ensure all required documents are submitted. Ensure email is less than 20 megabytes.

Submit your application by email:

• j1visa@hc-sc.gc.ca
  Subject: Application for Statement of Need, "Your Name"

Applicants who obtain a Preliminary Year and a residency must apply for a Statement of Need for both at the same time (include both preliminary and categorical application in the same email).