"Family Medicine Sponsorship Program Application Form" - Prince Edward Island, Canada

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FAMILY MEDICINE SPONSORSHIP PROGRAM
APPLICATION FORM
Application DEADLINE: November 30, 2020
This application is open to medical students enrolled in a recognized Canadian Medical School who are currently in their
fourth year of medical learning and are interested in pursuing a career in Family Medicine.
To apply for this program the following documentation is required along with a completed application form:
Current curriculum vitae ;
Latest official transcripts. It is the responsibility of the applicant to ensure their educational institution provides the
Recruitment and Retention Secretariat with their latest official transcripts (from all completed years of medical
school);
An essay (3-5 double-spaced pages) identifying why you believe you should be chosen to participate in the PEI
Family Medicine Sponsorship Program, and what you would bring to the province as a new physician practicing in
rural Prince Edward Island; and
Three (3) letters of reference from clinical preceptors and/or medical school professors.
*Please note: Preference will be given to Prince Edward Island residents.
In return for sponsorship funds to support educational expenses, and upon successful completion of family medicine residency
training, the successful applicant must provide the province of PEI with a 5-year return-in-service commitment in the area of
greatest need. The area of greatest need will be identified by Health PEI and the Department of Health and Wellness, upon
completion of residency training. The student is required to sign a Return-in-Service agreement before any funds are issued. If
these requirements are not met, the applicant shall be required to return the full amount of the sponsorship funds received.
Sponsored students must be successful in passing all Canadian examinations and obtaining licensure with the College of
Physicians and Surgeons of Prince Edward Island. If these requirements are not met, the applicant shall be required to return
the full amount of sponsorship funds received.
1. APPLICANT INFORMATION (Please Print)
First Name _____________________________________________
Middle Name ___________________________________________
Last Name _____________________________________________
Alternate Contact, excluding spouse and children
Previous name if applicable
(Mandatory)
Number, Street, PO Box
Name and Telephone #
City
Prov
Postal
Number, Street, PO Box
Page 1
FAMILY MEDICINE SPONSORSHIP PROGRAM
APPLICATION FORM
Application DEADLINE: November 30, 2020
This application is open to medical students enrolled in a recognized Canadian Medical School who are currently in their
fourth year of medical learning and are interested in pursuing a career in Family Medicine.
To apply for this program the following documentation is required along with a completed application form:
Current curriculum vitae ;
Latest official transcripts. It is the responsibility of the applicant to ensure their educational institution provides the
Recruitment and Retention Secretariat with their latest official transcripts (from all completed years of medical
school);
An essay (3-5 double-spaced pages) identifying why you believe you should be chosen to participate in the PEI
Family Medicine Sponsorship Program, and what you would bring to the province as a new physician practicing in
rural Prince Edward Island; and
Three (3) letters of reference from clinical preceptors and/or medical school professors.
*Please note: Preference will be given to Prince Edward Island residents.
In return for sponsorship funds to support educational expenses, and upon successful completion of family medicine residency
training, the successful applicant must provide the province of PEI with a 5-year return-in-service commitment in the area of
greatest need. The area of greatest need will be identified by Health PEI and the Department of Health and Wellness, upon
completion of residency training. The student is required to sign a Return-in-Service agreement before any funds are issued. If
these requirements are not met, the applicant shall be required to return the full amount of the sponsorship funds received.
Sponsored students must be successful in passing all Canadian examinations and obtaining licensure with the College of
Physicians and Surgeons of Prince Edward Island. If these requirements are not met, the applicant shall be required to return
the full amount of sponsorship funds received.
1. APPLICANT INFORMATION (Please Print)
First Name _____________________________________________
Middle Name ___________________________________________
Last Name _____________________________________________
Alternate Contact, excluding spouse and children
Previous name if applicable
(Mandatory)
Number, Street, PO Box
Name and Telephone #
City
Prov
Postal
Number, Street, PO Box
Page 1
Telephone#
Alternate Tel #
City
Prov.
Postal
E-Mail Address
E-Mail Address
2. ACADEMIC INFORMATION (Please Print):
a) Name of Canadian Medical School currently attending:
_________________________________________________
b) Year of study:
c) Anticipated graduation date:
4 RESIDENCE STATUS:
I am a Canadian Citizen.
Yes
No
If no:
I am a landed immigrant or have permanent resident status.
Yes
No
(Please attach a copy of your certificate)
Note:
To guarantee an applicant will be able to fulfill the terms of the agreement, you are required to be a Canadian Citizen or have
landed immigrant or permanent resident status at the time of application.
What is your province of legal residence? _____________________________________________________
To be considered a resident of PEI, you must have graduated from a PEI high school, or are a dependent student whose parents are PEI
residents, or have lived in PEI for greater than or equal to 12 months while NOT a student at any post-secondary institution.
6. DECLARATION BY APPLICANT:
A)
I hereby certify the information given on this application is complete and true in all respects.
B)
I declare that the PEI Department of Health and Wellness has my authorization to collect information about me and
exchange information about me, as it considers necessary, from any level of government in Canada and education
institutions. Any collection, use, or disclosure of personal information must be in accordance with the Freedom of
Information and Protection of Privacy Act R.S.P.E.I. 1998, c. F-15.01.
Application Date
Student Signature
NOTE: Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act
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R.S.P.E.I. 1988, c. F-15.01, as it relates directly to and is necessary for Family Medicine Sponsorship Program and will be used
for this purpose. If you have any questions about this collection of personal information, you may contact the Recruitment and
Retention Secretariat.
OTHER:
·
It is your responsibility to ensure that all relevant information has been included or attached.
·
Incomplete applications will not be considered.
ADDITIONAL INFORMATION:
If you have questions or require assistance, please contact us by:
·
Telephone: 902-368-6302 or 902-620-3874 or Fax: 902-620-3875
·
E-mail:
healthrecruiter@gov.pe.ca
PLEASE SCAN AND SUBMIT YOUR COMPLETED APPLICATION TO:
Recruitment & Retention Secretariat
Attention: Family Medicine Sponsorship Program
healthrecruiter@gov.pe.ca
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