General & Thoracic Surgery Fellowship Application

Type of Fellowship

Requested start date

Personal information

First Name:

Middle Name:

Last Name:

Date of birth

Place of birth

Citizenship

Canadian Landed Immigrant

Languages spoken fluently

Other languages

Contact information

Email address

Home Telephone Number

Work Telephone Number

Work Fax Number

Current address

Street Address

Suite/Unit Number (if applicable)

City/Town

Country

Postal Code

Permanent address

Street address

Suite/unit number (if applicable)

City/Town

Country

Postal Code

Education

University

City

Country

National Training Number (NTN) for United Kingdom trainees only

Degree obtained

Year

Are you registered with The College of Physicians & Surgeons of Ontario?

Examinations

Medical Council of Canada Evaluating Exam (MCCEE) - date passed

Medical Council of Canada Qualifying Exam (MCCQE) - date passed

Test of English as a Foreign Language (TOEFL) - mark (minimum 237)

Test of Spoken English (TSE) - mark (minimum 50)

Type of license

General

License number

Date of expiry

Specialty

Number

Date of expiry

Educational

Number

Date of expiry

Upload supporting files

Upload your CV

Upload Letter of Reference 1

Upload Letter of Reference 2

Upload Letter of Reference 3

Personal Information (PI) collected in this form will only be used for the purpose defined above and will only be retained for the period of time required to fulfill the purpose for which we collected it or as permitted and/or required by law. The hospital takes reasonable steps to protect your information from theft, loss and unauthorized use and/or disclosure. You may contact the General & Thoracic Surgery Education Coordinator if you have any questions about this form/program/process or if you do not want to provide any PI using the form. If you have general questions about the Hospital’s information practices, please contact privacy.office@sickkids.ca.