Visiting Postgraduate Electives Application

For rotations within the rural region including Windsor.

Fields denoted by an asterisk (*) are required.

Name Name First Last
Preferred First Name
Email Address
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Date of Birth
Gender
Citizenship (for International Trainees only):
Home university student number:
Educational Information
Current University:
Current Residency Program:
Current Level of Training:
Program Administrator's Name Program Administrator's Name First Last
Program Administrator's Email
CPSO# (Please indicate N/A if not a valid license holder):
CMPA/AQESSS#:
Please upload proof of CMPA/AQESSS coverage for Ontario:

Attach Files
Rotation Information

1st Choice Request
Rotation Start Date Rotation Start Date / MM / DD YYYY
Rotation End Date Rotation End Date / MM / DD YYYY
Rotation Specialty Requested
Rotation Location Requested
Rotation Type

Rotation Type Core Elective
Name of Preceptor (if known)
2nd Choice Request
Rotation Start Date Rotation Start Date / MM / DD YYYY
Rotation End Date Rotation End Date / MM / DD YYYY
Rotation Specialty Requested
Rotation Location Requested
Rotation Type

Rotation Type Core Elective
Name of Preceptor (if known)
3rd Choice Request
Rotation Start Date Rotation Start Date / MM / DD YYYY
Rotation End Date Rotation End Date / MM / DD YYYY
Rotation Specialty Requested
Rotation Location Requested
Rotation Type

Rotation Type Core Elective
Name of Preceptor (if known)
Please provide any additional comments you feel would be beneficial to your application.
Do you have access to a vehicle during your rotation?

Do you have access to a vehicle during your rotation? Yes No
Will you require accommodations (if available) during this rotation?

Will you require accommodations (if available) during this rotation? Yes No
Upload your CV:

Attach Files
For trainees not enrolled in residency training in Ontario: Upload a copy of your Medical Degree:

Attach Files
Upload your Letter of support from your home program director:

Attach Files
By clicking the button below you are confirming all information submitted on this form is accurate and true.

By clicking the button below you are confirming all information submitted on this form is accurate and true. I AGREE
The personal information on this form is collected under the authority of the University of Western Ontario Act, 1982. The information is collected for the purpose of processing your application for a visiting elective. For further information about this collection, please contact the Postgraduate Program Coordinator, Distributed Education Network, Schulich School of Medicine & Dentistry, The University of Western Ontario, 519-858-5152

Visiting Postgraduate Electives Application

Visiting Postgraduate Electives Application

Educational Information

Rotation Information