Fillable Postgraduate Training Licence PGY 1 (Nova Scotia Agricultural College)

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Postgraduate Training Licence PGY 1 (Nova Scotia Agricultural College)

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Postgraduate Training Licence
PGY 1
Dear appl
icant,
Congratulations on matching to a training program with Dalhousie University!
Enclosed is the application and checklist for a Postgraduate Training licence with the College of Physicians and Surgeons of Nova
Scotia (the College) and is designed for physicians who have matched to a training program with Dalhousie University.
Please do not wait until you recieve your medical degree to submit the application.
Please review the attached documentation list carefully. Be sure to include the attached documentation checklist along with
your completed application package. Mark an ☒ in each checkbox once you enclose the item. A checkbox denotes
attachments you are required to provide with the completed application form. If there is no checkbox, the document will be
requested by the College.
Confirmation of receipt of your application will be sent to y
ou by e-mail. If you do not receive an email confirmation after two
weeks from the submission of your application, please contact the College at registration@cpsns.ns.ca
.
You will be
provided with a username and password to access the College’s Application Documentation Status (ADS) website.
The ADS website will provide you with:
• a contact at the College; and
• the current status of your application; and
• the documentation that has been received to date; and
• any documentation that is still outstanding; and
• documentation expiry dates.
The ADS web
site is typically updated within 2-3 business days.
Incomplete applications will result in a delay in obtaining a Postgraduate Training licence. You must provide the College with a
completed application form no later than May 15
th
to allow enough time for processing by the Registration Department. You
must obtain confirmation of your licence from the College prior to commencing your training in Nova Scotia.
Please not
e: If you are a Dalhousie University Medical School trainee based in New Brunswick or Prince Edward Island but will
be doing rotations in Nova Scotia at any time during the academic year, you must register with the Nova Scotia College prior to
commencing any training in Nova Scotia.
Regards,
Registrat
ion Department
Clear
FORMS
1
Postgraduate training application form. To be completed by you the principle
applicant.
2
Credentials Source Verification Form
3
MINC Consent Form
It is mandatory in Nova Scotia to have a MINC number. All applicants must sign and date the
enclosed Consent for Release of Information form.
A complete description of MINC can be obtained on its website:
http://www.minc-nimc.ca
4
Declaration of Gaps in Training or Practice Form*
*Please complete if you have any gaps in training or practice longer than one month in your
history of training/practice. If you do not have any gaps in training or practice, please write no
gaps in training followed by your initials.
5
Fee Payment
You will be invoiced for the licensing fee upon receipt of your application.
PHOTOS
6
1 passport size photo.
PHOTOCOPIES OF IDENTITY
Do not send original documents of the following as they will not be returned.
7
Please provide a copy of one of the following (the copy will not be accepted if it is expired):
Passport
Permanent Resident Card
Driver’s licence
8
Medical Degree/Diploma *
A copy of your Canadian Medical Degree and any Medical Degrees issued from outside of
Canada, must be provided with your application.
Medical Degrees issued from outside of Canada require verification through physiciansapply.ca.
If your medical degree is not In English, you must also submit an original official translation for
verification.
*If this is not available at the time of application, please provide the College with a copy as soon
as it becomes available.
9
Medical Council of Canada Examinations*
Please allow the College access to your physiciansapply.ca documents to confirm your Medical
Council of Canada exams.
*If this is not available at the time of application, please provide the College with access as soon
they become available.
SUPPORTING DOCUMENTATION
10
Curriculum Vitae
Your Curriculum Vitae must include, at a minimum:
• Undergraduate medical education information and date of graduation
• A list, in chronological order (month/year) of all your postgraduate training
appointments including, durations and level of training in each jurisdiction since
graduation.
• A list, in chronological order (month/year) of all your professional appointment and
type of practice including names of hospitals and/or clinics, discipline, duration and
location (please specify the city, province/state, country)
• A list of all your previous and current medical licenses including type, duration, licence
number and jurisdiction.
• A list of specialist and other postgraduate examinations and qualifications. E.g. Medical
Council of Canada examinations, USMLE, CST, ECFMG etc.
Please note:
We recommend completing this application on a desktop computer. Completing it on a tablet or cell phone may
not allow you to complete the form accurately or completely.
If you have a "Yes" response to any questions, you may be required to submit a separate document for
information.
Please ensure you have the correct version of Adobe. Click here to download
•
•
•
Please email the completed application to registration@cpsns.ns.ca
Any gaps longer than three months in your history of training/practice must be clarified in the
declaration of gaps in training form.
11 Evidence of Postgraduate Training
Please provide documented evidence of postgraduate training completed to date.
The document must be in *English and indicate the scope of practice and the start/
end dates. The document must be submitted to physiciansapply.ca for source
verification. *For documents not issued in English, you must also submit the original
notarized translation to physiciansapply.ca for verification. This can be provided by a
completion of training certificate, or written confirmation from the program director
for your training program.
12
English
Language Proficiency testing.*
*Applicable only to those who do not meet the English language requirement as outlined in the
CPSNS Policy - English Language Proficiency for Postgraduate Training Licence
THIRD PARTY DOCUMENTATION
You must arrange for the following documents below to be sent directly to the College by third party
organizations. Source documentation sent by you will be rejected.
13 Certificate of Professional Conduct
If you have a medical degree and completed postgraduate training or practised medicine in a country
outside of Canada prior to applying for your Nova Scotia licence, the College requires a Certificate of
Professional Conduct from all regulatory authorities in whose jurisdiction you hold or have ever held
any type of licence or registration in the previous 10 years.
This does not include any Medical Student Electives.
A Certificate of Professional Conduct must be dated within the immediate 90 days prior to a licence
being granted in Nova Scotia (e.g if you require your Nova Scotia licence by July 1
st
then the
certificate should not be requested any earlier than April 1
st
).
Please note: Most regulatory authorities charge a fee for Certificates of Professional Conduct.
14 Confirmation of training program from Dalhousie University
The Dalhousie Postgraduate Medical Education office will provide the College with confirmation of
your upcoming training.
Postgraduate Training Licence
PGY1
Please complete and return this fillable application form to the College by
email. Acrobat Reader is required. This is
available as a free download
from the Adobe website. Please provide your
signature on all the required documents
before emailing to the College.
The College will accept e-signatures. This application may also be mailed, faxed or
couriered to College.
Please ensure there are no missing pages and all documents are source
verified through physiciansapply.ca.
Application forms are valid for six months from the date of completion.
a)
Last Name First Name Middle Name(s)
b)
Name (if different on medical degree).
Please provide evidence to support name change. Any discrepancy in how you name appears on the valid ID
documents submitted with this application must be explained.
Female
c)
Gender: Male
YYYY/MM/DD
f)
Are you a Canadian Citizen? Yes No
g)
Are you a Permanent Resident (Landed Immigrant)? Yes
No
N/A
h)
Do you hold a Work Permit? Yes
No
N/A
1. Personal Information
e) Country of birth:
d) Date of birth:
a)
Current Mailing Address:
Street Address Apt/Suite #
City/Town Province/State
Postal Code
b)
Nova Scotia Mailing Address (if known and different from current). You will need to provide a contact address in
Nova Scotia for the
period you will be in the province.
Street Address Apt/Suite #
City/Town Province/State
Postal Code
Date Effective:
YYYY/MM/DD
c)
Email address:
As part of your application process, you may receive information pertaining to your application that is timely and
confidential. It is therefore your responsibility to ensure that your email address is up-to-date and secure.
d) Home Phone: Cell Phone:
Fax Number:
(XXX) XXX – XXXX
(XXX) XXX – XXXX
You will be asked to sign a Credentials Source Verification Agreement Form for the purpose of enabling the College to
issue you a licence in advance of receipt of a final source verification report in physiciansapply.ca.
Confirmation of your medical degree can be provided through sharing your profile on physiciansapply.ca. Please select
‘share’ with the College of Physicians and Surgeons of Nova Scotia.
a)
Medical Degree:
b)
Province:
c)
Granting Institution:
d)
Date Granted/Date Expected to be Granted:
YYYY/MM/DD
2. Contact Information
3. Credentials
e)
Period you were enrolled at this University or School of Medicine:
Start Date: End Date:
YYYY/MM/DD
YYYY/MM/DD
f)
Before you graduated from the University or School of Medicine named above, did you attend any other University or
School of Medicine?
Yes
No
If “Yes”, please specify:
Name of University or
School of Medicine
Location
Language of Instruction
Dates
(YYYY-MM) to (YYYY-MM)
g)
Applicants must meet the English language requirement as outlined in the policy English Language Proficiency for
Postgraduate Training Licence.
Language Proficiency: English
French
Other:
(Check all that apply) Please specify
h)
Language of instruction and/or language primarily used in patient care during the clinical parts of your education
at the University or Sch
ool of Medicine granting your Medical Degree:
English French
Other:
Please specify
Please provide the College access to at least one of the following documents with your application. Please refer to
the College
Registration Policy - Examinations Required for Registration on the Education Register.
a)
Graduates of Canadian med
ical schools are required to have attained a pass in the MCCQE Part I.
Please indicate either 'Pending, Complete or Incomplete' in the Status Section.
Number of Attempts
b) Successful completion of one of the following is required for graduates of non-Canadian medical schools.
Please provide documented evidence of postgraduate training completed to date. This can be provided in the
form of a completion of training certificate or written confirmation from the program director for your training
program. The document must indicate the scope of practice and the start/end dates.
a)
Current Year of Postgraduate Training:
b)
Program Information:
Program/University/Country
United States Medical Licencing Exam (USMLE)
Steps
1, 2, & 3
Examination Date Step 1:
(YYYY/MM/DD)
Examination Date Step 2:
(YYYY/MM/DD)
Examination Date Step 3:
(YYYY/MM/DD)
Federation Licensing Examination (FLEX)
Components 1 and 2
Examination Date:
(YYYY/MM/DD)
National Board of Medical Examiners (NBME)
Parts I, II, & II
Examination Date:
(YYYY/MM/DD)
The Comprehensive Osteopathic Licensing
Examination (COMLEX-USA) Levels 1, 2, and 3.
(This applies only to graduates of osteopathic schools
accredited by the American Osteopathic Association).
Examination Date Step 1:
(YYYY/MM/DD)
Examination Date Step 2:
(YYYY/MM/DD)
Examination Date Step 3:
(YYYY/MM/DD)
4. Medical Council of Canada Examinations
5. Postgraduate Training
Examination Date: (YYYY/MM/DD)
Status: Pass, Pending, Fail
MCCEE
MCCQE Part 1
MCCQE Part II (LMCC)
Number of Attempts
Number of Attempts
Examination Date: (YYYY/MM/DD)
Examination Date: (YYYY/MM/DD)
Status: Pass, Pending, Fail
Status: Pass, Pending, Fail
c)
Anticipated length of training: to
Start date (YYYY/MM/DD) End date (YYYY/MM/DD)
d)
Have you previously been registered and licensed by the College of Physicians and Surgeons of Nova Scotia?
No Yes
Date:
(YYYY/MM/DD)
e)
Postgraduate medical training completed in Canada. Please list Residency Training in chronological order. Should
there be any gaps in training or practice, please complete the Declaration of Gaps in Training or Practice form.
Position Held
Discipline
Institution
Country
Date
YYYY-MM to YYYY-MM)(
f)
Postgraduate medical training completed outside of Canada. Please list residency training in chronological order.
Should there be any gaps in training or practice, please complete the Declaration of Gaps in Training or Practice
form.
Position Held
Discipline
Institution
Country
Date
(YYYY-MM to YYYY-MM)
In chronological order, please list the names of every jurisdiction in which you have been licensed, including your
postgraduate training. If additional entries are required, please attach in a separate document.
Jurisdiction
(Province or State and
Country)
Licence/Registration
#
Nature/Type of PGT and
Medical Practice
Dates
(YYYY-MM to YYYY-MM)
Registration and Licensing History6.
Each question must be answered carefully and honestly. Any errors, discrepancies or omissions in your
answers, no
matter how minor, will delay your application and may require review by the College’s
Registration Committee.
For any “yes” response, you must provide a detailed explanation accompanied with supporting
documentation.
Without this information the College cannot proceed with your application. Following
receipt of this information
you may be asked for further explanation or documentation.
Please answer the following questions. If “yes”, please provide detailed explanation.
7.1 Have you ever had an application for medical licence, certificate of registration, or
permit to practice:
• rejected
; or
• refused; or
• denied?
If Yes, provide additional information:
YES NO
7.2
Have you ever had a medical licence, certificate of registration, or permit to
practice:
• revoked; or
• suspended; or
• restricted in any way?
If Yes, provide additional information:
7.3
Are you presently or have you ever been subject to:
• an allegation; or
• complaint; or
• request for investigation for any reason whatsoever by a medical licensing or
regulatory authority?
If Yes, provide additional information:
7.4
Are you aware of any inquiry likely to be made by a medical licensing or regulatory
authority, or otherwise:
• with respect to your conduct; or
• competence; or
• capacity; or
• fitness to practice?
If Yes, provide additional information:
7. Capacity, Competence and Character
YES NO
YES NO
YES NO
7.5
Have you ever been:
• charged with; or
• convicted; or
• found guilty of; or
• pleaded guilty to; or
• pleaded no contest to; or
• filed any similar plea for a criminal offense?
7.6
If Yes, provide additional information:
During your undergraduate medical education, have you ever:
• withdrawn; or
• been expelled; or
• been suspended; or
• been put on probation; or
• required remediation by a medical school or educational institution for any
reason; or
• resigned in lieu of an inquiry?
If Yes, provide additional Information:
7.7
During any of your internship, residency, fellowship, postgraduate training,
educational or other institutional training, have you ever been:
• investigated; or
• suspended; or
• removed, dismissed, expelled, prematurely terminated from the program; or
• put on probation; or
• put on remediation; or
• withdrawn from your program; or
• been subject to revocation of your training program; or
• withdrawn or resigned from any of your postgraduate medical training?
If Yes, provide additional information:
7.8
7.9
8.0
Have you been harmfully involved with drugs or alcohol or received
treatment relating to your use of drugs or alcohol?
If Yes, provide additional information:
Apart from routine illness, at any time during your undergraduate or
postgraduate training, did you have any health condition that could have
limited your ability to practice/train in medicine competently and
safely? If Yes, provide additional information:
Have you taken a leave of absence from your training program of one month or
longer?
If Yes, provide additional information:
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
8.1
Is there any event, circumstance, condition or matter not disclosed in your
answers to the
preceding questions in respect to your character, conduct,
competence or capacity that
might be an impediment to your application for a certificate of registration to practise
medicine in the province of Nova Scotia?
If Yes, provide additional information:
In submitting this application, I understand that it is my responsibility to be familiar with and abide by the
provisions of the College's policies and guidelines, available here.
I accept the College’s Privacy Policy and agree to the College’s use and disclosure of my personal
information for the purposes set out in Part 2 of that Policy.
I confirm that I will immediately report to the College should anything occur while licensed that would
alter my responses to any of the questions contained in this application.
I accept that any information provided by me to the College may be used by the College for any regulatory
purpose or shared by the College with stakeholders, including but not limited to Dalhousie University, the
Nova Scotia Health Authority, the IWK, or other medical regulatory authorities, as needed.
I understand that the College may seek to verify and obtain any information related to this application and
ongoing licensure, and in so doing may seek information from other medical regulatory authorities,
Medical Council of Canada, the College of Family Physicians of Canada, the Royal College of Physicians and
Surgeons of Canada, or other institutions or persons. I hereby consent to the College doing so.
I declare that the information provided in this application for licence renewal is true and accurate, to
the best of my knowledge. I make this declaration knowing that the provision of false information in
the application, whether false by commission or omission, may be considered professional misconduct
and may result in the revocation of any licence that has been issued to me.
You must click the button to declare.
Full Na
me: ___________________________________
Date: _______________________________________
8. Application Authorization and Declaration
YES NO
Consent for Release of Information
What You Need to Know about MINC Numbers
A medical identification number system has been developed with
the goal of providing a reliable means of identifying every
individual in the Canadian medical education and practice systems.
A not-for-profit corporation (whose legal name is noted above),
known as “MINC#NIMC”, has been incorporated by the Federation
of Medical Regulatory Authorities of Canada (FMRAC) and the
Medical Council of Canada (MCC) for the sole purpose of
administering the MINC number system.
A MINC number will be issued to all individuals (who consent in
writing) at the time of their initial, even temporary, entry to any
aspect of the Canadian medical education or practice systems,
including undergraduate students, postgraduate trainees,
applicants to the MCC examinations, and physicians of any
registration status.
Once assigned, an individual’s MINC number will remain
unchanged throughout his/her entire medical career. Assigned
numbers will never be reused, even after the death of the
individual. Individuals will carry the same MINC number, even if
they leave Canada and return, move between jurisdictions or
change registration status. No information is encoded in an
individual’s MINC number, other than a country code (CA for
Canada) and a profession code (MD for Medicine). The MINC
number does not imply any special privilege, rights or status; it is
simply a series of letters and numbers for identification purposes.
Upon the consent of an individual, the MCC or a provincial/
territorial medical regulatory authority will submit personal
information to MINC#NIMC as follows: name(s), gender, date of
birth, country of birth and year and university of graduation (note:
previous names if applicable and other identifiers if necessary to
confirm identity may also be submitted), collectively referred to as
the Core Information.
MINC#NIMC will use Core Information to either generate or
confirm a MINC number for individuals and will retain the Core
Information and its associated MINC number in its system for the
purposes of uniquely identifying individuals and ongoing identity
confirmation by Prime and Licensed Users of the MINC system.
Not-for-profit and public sector organizations that are involved in
the education, certification, licensure or professional practices of
physicians in Canada may apply to MINC#NIMC for a license to use
the MINC number system as a means of:
(i) accurately identifying individuals with whom they have
dealings,
(ii) processing information relating to those individuals, and
(iii) linking or exchanging physician information with other
Licensed or Primary Users for Approved Purposes such
as the compilation of statistics, the development of
profiles, the administration of programs or benefits, the
management of the health system and research.
Licensees agree to comply with MINC#NIMC’s Privacy Code, with
privacy, security and confidentiality provisions, and with
applicable privacy legislation as part of their licensing agreements.
The MCC and the twelve Canadian medical regulatory authorities
will have controlled access to both MINC numbers and Core
Information in order to facilitate the performance of their
regulatory responsibilities. The only information that shall be
disclosed to Licensed Users shall be the MINC numbers for their
own members.
For a more complete description of MINC#NIMC, including the
details of its Privacy Code and a list of all Licensed Users and
their approved uses, consult its website at www.minc-nimc.ca,
or contact MINC#NIMC directly at:
2283 St. Laurent Blvd., Suite 100
Ottawa, ON Canada K1G 5A2
Phone: 613-288.2792 – 1.855.288.2783
Info@minc-nimc.ca
www.minc-nimc.ca
I have read and understand the above information, and consent to the release of my information to MINC#NIMC for the purpose of
generating a MINC number that will be permanently assigned to me. I further consent to MINC#NIMC disclosing the MINC number and
personal information to Prime and Licensed Users, as outlined above.
_________________________________________________________________________ ________________________________________________________
Signature Date
_________________________________________________________________________
Name Printed
X:\Data\Registration Dept\Forms & Certificates\Declaration Form - Source Verification Agreement.doc
Registration Department
Suite 5005 -7071 Bayers Road
Halifax, Nova Scotia
Canada B3L 2C2
Phone: (902) 422-5823 Toll –free: 1-877-282-7767
Fax: (902) 422-5035
Email: registration@cpsns.ns.ca
www.cpsns.ns.ca
CREDENTIALS SOURCE VERIFICATION AGREEMENT
I, Dr. an applicant for registration with the College of
Physicians & Surgeons of Nova Scotia (College) understand that as part of the registration process in Nova Scotia I am
required to have various documents source verified in the Medical Council of Canada (MCC) Physician Credentials
Repository, through physiciansapply.ca.
Prior to registration being granted:
(a) I will register an account in physiciansapply.ca and submit a request to have my documents source verified;
(b) I will share my credentials file with the College in physiciansapply.ca to enable them to view the documents I
have submitted and to follow the status of the source verification process;
(c) I am signing this agreement for the purpose of enabling the College to issue my licence in advance of receipt
of a final source verification report in physiciansapply.ca.
I, therefore, request that the College issue a licence once the College is able to view my submitted documents via the
physiciansapply.ca portal and I have met all other requirements for licensure in Nova Scotia.
I understand that if my credentials cannot be verified to the satisfaction of the College, my registration with the College
will be immediately revoked.
I am aware that I have the right to seek legal advice with respect to this agreement.
Signed by me in the City of , in the Province/State of
this day of , 20 .
Signature of Witness Signature of Applicant
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Postgraduate Training Licence PGY 1 (Nova Scotia Agricultural College)

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