Northern Medical Services - Medical Staff Application

MEDICAL STAFF APPLICATION
NORTHERN MEDICAL SERVICES
UNIVERSITY OF SASKATCHEWAN

NAME (surname) (given names)

ADDRESS:

Postal Code:

TELEPHONE Day: Evenings:

CITIZENSHIP STATUS: SOCIAL INSURANCE NO.

POSITION APPLIED FOR: PERMANENT (one year or more)

TEMPORARY (less than one year)

Date Available: Length of time available:

EDUCATION

Premedical Education

University: Year of Graduation:

Degree:

Medical School (please attach photocopy of diploma):

University:
Degree:
Year of Graduation:

Postgraduate Clinical Education

Internship, Hospital/University:

Rotations and Duration:

Completion Date:

Residency (Further Post-grad. Education - attach additional sheet if necessary)

Institution and Location Dates Position Held

Recognized Courses (please attach photocopy of certificate) Advanced Trauma Life Support
Advanced Cardiac Life Support

ECG Interpretation (College of Physicians and Surgeons of Sask.)

Paediatric Advanced Life Support

LICENSING AND CERTIFICATION

Province(s) of licensure (attach photocopy):

Certification by Canadian College of Family Physicians Yes
No

Other Certification

EMPLOYMENT EXPERIENCE: (attach additional sheet if necessary)

Dates Institution/Practice and Location Position Held

REFERENCES

Name and Address (including postal code and telephone number) Title

1.

2.

3.

OTHER INFORMATION: (publications, etc.)

I hereby authorize any of the institutions, persons or authorities named in my application to give such information to Northern Medical Services as it may require for the purpose of making a decision with respect to my application for employment. I certify that the information provided by me in this application is true and complete to the best of my knowledge.

Date: Signature of applicant:

ENCLOSURES (if applicable): Photocopies of medical diploma, recognized course certificates, provincial medical licenses and certificates of the Canadian College of Family Physicians.

Send by mail or facsimile to: NORTHERN MEDICAL SERVICES
404, 333-25th Street East
Saskatoon Saskatchewan S7K 0L4
Canada Telephone:
(306) 665-2898
FAX:
(306) 665-6077

Return to eligibility requirements page

NAME	(surname)	(given names)
ADDRESS:
		Postal Code:
TELEPHONE	Day:	Evenings:
CITIZENSHIP STATUS:		SOCIAL INSURANCE NO.
POSITION APPLIED FOR:	PERMANENT (one year or more)
	TEMPORARY (less than one year)
Date Available:	Length of time available:

EDUCATION
Premedical Education
University:		Year of Graduation:
Degree:
Medical School (please attach photocopy of diploma):
University: Degree:		Year of Graduation:
Postgraduate Clinical Education
Internship, Hospital/University:
Rotations and Duration:
		Completion Date:
Residency (Further Post-grad. Education - attach additional sheet if necessary)
Institution and Location	Dates	Position Held



Recognized Courses (please attach photocopy of certificate)	Advanced Trauma Life Support Advanced Cardiac Life Support ECG Interpretation (College of Physicians and Surgeons of Sask.) Paediatric Advanced Life Support

LICENSING AND CERTIFICATION
Province(s) of licensure (attach photocopy):
Certification by Canadian College of Family Physicians	Yes No
Other Certification

EMPLOYMENT EXPERIENCE: (attach additional sheet if necessary)
Dates	Institution/Practice and Location	Position Held

REFERENCES
Name and Address (including postal code and telephone number)	Title
1.
2.
3.

OTHER INFORMATION: (publications, etc.)

I hereby authorize any of the institutions, persons or authorities named in my application to give such information to Northern Medical Services as it may require for the purpose of making a decision with respect to my application for employment. I certify that the information provided by me in this application is true and complete to the best of my knowledge.
Date:	Signature of applicant:
ENCLOSURES (if applicable): Photocopies of medical diploma, recognized course certificates, provincial medical licenses and certificates of the Canadian College of Family Physicians.
Send by mail or facsimile to:	NORTHERN MEDICAL SERVICES 404, 333-25th Street East Saskatoon Saskatchewan S7K 0L4 Canada	Telephone: (306) 665-2898 FAX: (306) 665-6077