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Fellowship Application 2019

Please look at entire form before you begin completing it.  You will be required to upload several documents, plus be ready to provide email addresses of 3 referees who will be sent requests for references. Please note that the start date of the Fellowship Program is July 1, 2019.

Do not change START DATE from July 1 without permission.
You can put several languages into the "other" box, separating them by comma.

FUNDING
Are you applying for a funded position or will you be arranging your own funding?


CONTACT INFORMATION


PROGRAM

Only apply to those programs (3 maximum) that you are seriously considering. After your interviews, you will be asked to rank your site preferences (where applicable).


CERTIFICATION (Licence, Specialty, etc.)

 


TRAINING

RADIOLOGY TRAINING


MEDICAL SCHOOL


REFERENCES

Your three referees will have to send letters of reference directly to the Fellowship Program. Requests will automatically be sent to the email addresses you provide, with instructions on how and where to email their references. One of your referees should be your Radiology Residency Program Director (or equivalent individual). If your Program Director cannot provide a reference, please send us an explanation. An application is not complete until three letters of reference have been received.  It is suggested that you also contact your referees to make sure they have received and responded to requests for references.
Please input the email address of Referee #1. Referee #1 should also be your Program Director. The Referee will be automatically contacted so that they can provide a reference.
Please input the email address of Referee #2. The Referee will be automatically contacted so that they can provide a reference.
Please input the email address of Referee #3. The Referee will be automatically contacted so that they can provide a reference.
Additional comments about references can be input here. For example, if you are unable to get a reference from your program director, please explain here.

Please provide us with the following documents.  You may compile mulitple documents as a single document for the "Degrees, Certificates, and Licenses" section, if applicable.
Your application will not be considered complete without submitting these files. After browsing for the file after clicking "choose file", DO NOT CLICK the UPLOAD buttons. Documents will be uploaded when you submit the form.

Please up load as a single document. Please provide as a pdf.
Files must be less than 2 MB.
Allowed file types: pdf.
Please up load as a single document. Please provide as a pdf. You can send this to us later if it is not yet available.
Files must be less than 2 MB.
Allowed file types: pdf.
Files must be less than 2 MB.
Allowed file types: pdf.
Files must be less than 2 MB.
Allowed file types: pdf.

DECLARATION

(Must be completed by all applicants)

YesNo
Have you ever been convicted of a criminal offence for which a pardon has not been granted? *
Have you ever been convicted of any other offence that may affect your eligibility for Ontario Educational registration? *
Are there charges pending for an alleged offence that may affect your eligibility for Ontario Educational registration? *
Have you ever been subject to a disciplinary hearing of a medical licensing authority? *
Have you ever been denied licensure by a medical licensing authority or had such licensure revoked or limited? *
Have you ever been disciplined, suspended, or dismissed from an undergraduate or postgraduate educational program? *

I hereby certify that the information provided on this on-line form and attachments is true and complete.  I understand I shall be disqualified if information is withheld or false and that any appointment already made or in progress will be cancelled and all credit revoked.

By checking "Agree" you are affirming the above statement.

Please be aware that only those selected for an interview will be contacted directly by email.

You will receive a confirmation email once you succesfully submit this form.