English: Current M ailing Ad dresse s in (Ontario) (Quebec) (N ewfo und land& Labrador) (* Other Province) ______________________ _ _ _ _ _ _ _ _ _ _ _ _ _________________ _____________________________________ ____________________________ _ _ _ _ _ _ _ ______________________ _______________________________ __________________________________ _____________________________ _________________________ Perm anent Add ress in (O ntario) (Q uebec) (N ewfo und land& Labrador) (* Other Province) ___________________________________________________________________________ _____________ _________________________________________________________________________________ _______ ___________________________________________________________________________________ ____ _ Wo rk Num ber__________________Home_____________________Pager____________________________ Facsimile_______________________ E-Mail____________________________________________________ Country of Citizenship____________________________ _C oun try of B irth___________________________ Name & Country of Medical School___________________________________________________________ Year Medical Degree Awarded________________ * Previous attempt(s) to obtain training position in Family Medicine in Canada: c arm s ____________________ IMG-Ontario _____________________ Other _____________________ Date(s): ___________________ _ _ _ _ _ _ ________________________________________________________ Location(s): _ _ _ _ _____________________________________________________________________ ____ _ List all current and completed postgraduate medical training:
French: L NOM PRÉNOM Numéro de l’ECFMG Adresses postales actuelles (en Ontario), (à Terre-Neuve et Labrador) (autre province ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Adresse permanente (en Ontario), (à Terre-Neuve et Labrador) (autre province) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ No. de téléphone au travail _______________Maison________________Téléavertisseur______________ Télécopieur_______________________ Courriel________________________________________________ Pays de citoyenneté________________________________Pays de naissance________________________ Pays et nom de l’école de médecine ________________________________________________________ Année d’obtention du diplôme de médecin________________ Tentative(s) précédente(s) d’obtenir une formation en médecine familiale au Canada : CaRMS___________ IMG Ontario_______________ Autre programme__________________ Date(s) _________________________________________________________________________________ Lieu(x) :________________________________________________________________________________ ________________________________________________________________________________________ Préciser toutes les formations postdoctorales en médecine suivies :