Request for Verification of Undergraduate Medical Education

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Schulich School of Medicine & Dentistry Graduate Information
Graduate Name Graduate Name First Last
Middle Name
Graduate Email Address
Phone Phone - ### - ### ####
Extension
Year of Graduation
I am a third party completing this form on behalf of a graduate

I am a third party completing this form on behalf of a graduate Yes No
Third party name Third party name First Last
Third party job title/role
Does the graduate understand that you are making this request on their behalf

Does the graduate understand that you are making this request on their behalf Yes No
Year of Enrolment in Medical School
Organization/Institution Information
Name of Organization
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I have read the Credentialing webpage and understand that I am responsible for ordering my transcript and/or a copy of my diploma from the Office of the Registrar and having said documents sent directly to me or to the organization requesting said documentation.

Insert your name in the text field to acknowledge this statement.
Phone Phone - ### - ### ####
Extension
Fax Fax - ### - ### ####
Email
Contact Name (if known)
Documentation Required

Documentation Required Completion of Verification of Attendance forms Completion of Graduation Verification forms (with dates) Confirmation of English Language Proficiency Copy of Medical Student Performance Record Notarized Copy of Diploma Explanation of Special Circumstances (e.g. Extended Program, Remediation, Graduation Delay) Standard letter of verification with enrolment dates Other
Details of Special Circumstances:
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Request for Verification of Undergraduate Medical Education

Request for Verification of Undergraduate Medical Education

Schulich School of Medicine & Dentistry Graduate Information

Organization/Institution Information

Files to be uploaded: