Adult Critical Care Medicine Programme - Application for Residency/Fellowship Position

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Interview Date: October 22

 

                                      (Day)                (Month)                (Year)

 

Start Date Requested: (July 1st) Specify Year:                                    

Duration of Training Requested:                                                                                  

 

1.Personal Data

 

Current Mailing Address:                   

 

Street Address:		Apartment #:
City:		Province:
Postal Code:		Country:
Home Telephone:
Business Telephone:
Fax:
Pager:
Email:

 

Permanent Mailing Address:(if different from above)

 

Street Address:		Apartment #:
City:		Province:
Postal Code:		Country:
Home Telephone:
Business Telephone:
Fax:
Place of Birth:
Citizenship:
Social Insurance Number:

 

2.   Licensure:

 

Are you licensed to practice medicine in the Province of Ontario? (Yes/No):

Type of Ontario Licence:       

Independent Practice Licence                        Number:                                   

Educational Class Licence                           Number:                                   

 

Are you licensed to practice medicine outside the Province of Ontario? (Yes/No): 

If yes, please specify district, licence type and number: 

 

3. Education:

 

List Your Degrees (Academic & Professional) and Specialty Certifications

 

 

4.Postgraduate Training: (Please complete Appendix I)

 

5.Are you currently enrolled in a Postgraduate Training Programme? (Yes/No):

 

Programme:
University:
Name of Programme Director:

6.   If there has been an interruption in the pursuit of your medical career, please provide an explanation. Indicate the period of interruption and the reasons. 

                                                                                                                                                                   

                                                                                                                                                                   

                                                                                                                                                                   

                                                                                                                                                                   

7.Reference Letters:

A total of 3 reference letters are required. The CCM Programme will contact all referees directly. Please provide the names and addresses of (1) Current Programme Director (if applicable); and, (2) Letters from 2 or more individuals who have served in a supervisory capacity during your training.

 

Referees:
 

1.	Name:
	Address:
	Telephone:		Fax:
	Email:

 

2.	Name:
	Address:
	Telephone:		Fax:
	Email:

 

3.	Name:
	Address:
	Telephone:		Fax:
	Email:

 

 

Completed application forms should be sent to:

Dr. John T. Granton, Programme Director, Critical Care Medicine, University of Toronto
Consultant Pulmonary and Critical Care Medicine
Director Pulmonary Hypertension Programme
University Health Network,
TGH - 10 EN - 220
200 Elizabeth Street, Toronto Ontario Canada  M5G 2C4
Phone: (416) 340-4485   Fax: (416) 340-3359
John.Granton@uhn.on.ca

 

Please attach an updated copy of your Curriculum Vitae with this application.

Appendix I

 

4.Postgraduate Training

List chronologically all postgraduate experience to date, indicating the titles and dates of all clinical and research rotations, and the institutions concerned. (Use additional page if required.) 

 

PGY	Rotation Dates	Service	Hospital	University