Get Acsap

Surname Given Name Other name s if surname and/or given names have changed OR if alternate name s or different spelling s of your name s appear on documents Home Phone Cell Phone Pager Email Permanent Address Street Address Apartment/Unit City Province Country Postal Code Current Address if different from permanent address PART B LEGAL STATUS Are you a Canadian Citizen OR As of year Page - 1 - of 3 Landed Immigrant PART C PROGRAM SURVEY How did you learn about the Alberta Clinical and Surgical Assistant Program Please check all that apply. Website AHS Website Other College of Physicians and Surgeons of Alberta CPSA Previous ECAP or CCAP Participant Other IMG Licensed Physician AHS Physician or Employee Community Resource for Immigrants ie. Alberta Clinical and Surgical Assistant Program ACSAP Application Form PART A CONTACT INFORMATION It is the responsibility of the applicant to update the ACSAP office immediately regarding any changes to the information provided below. Surname Given Name Other name s if surname and/or given names have changed OR if alternate name s or different spelling s of your name s appear on documents Home Phone Cell Phone Pager Email Permanent Address Street Address Apartment/Unit City Province Country Postal Code Current Address if different from permanent address PART B LEGAL STATUS Are you a Canadian Citizen OR As of year Page - 1 - of 3 Landed Immigrant PART C PROGRAM SURVEY How did you learn about the Alberta Clinical and Surgical Assistant Program Please check all that apply. Document must be a photocopy of an original certified copy. IELTS Academic Version TOEFL IBT Academic Version PART E2 DOCUMENT SHARING CHECKLIST Do NOT send this documentation with your application package. Medical Degree Certificate and Transcripts Post Graduate Medical Education PGME Certificate Letter of Results giving MCCQE Part 1 Score Marriage Certificate Change of Name Document Affidavit of Differing Names Contact Information ACSAP ahs. Website AHS Website Other College of Physicians and Surgeons of Alberta CPSA Previous ECAP or CCAP Participant Other IMG Licensed Physician AHS Physician or Employee Community Resource for Immigrants ie. The Bredin Institute Alberta International Medical Graduate Program AIMGP Toronto IMG Symposium Other please specify PART D APPLICATION TERMS AND CONDITIONS PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY THEN SIGN AND DATE BELOW. I certify that i All of the information on this form and on all supporting documents submitted with respect to this application all of which together constitute the application package is true complete and correct and ii I agree that If any information contained in my application package is false or misleading or if any relevant information has been concealed withheld or not submitted as part of my application package my application package may at the sole option and discretion of Alberta Health Services be rejected from eligibility or If I have already commenced an ACSAP program my admission and enrolment may at the sole option and discretion of the Program Medical Director be cancelled or revoked and iii I will share the applicable documents with ACSAP via physiciansapply. Incomplete application packages will not be accepted. Submit your complete application package via email to ACSAP ahs. The Bredin Institute Alberta International Medical Graduate Program AIMGP Toronto IMG Symposium Other please specify PART D APPLICATION TERMS AND CONDITIONS PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY THEN SIGN AND DATE BELOW. I certify that i All of the information on this form and on all supporting documents submitted with respect to this application all of which together constitute the application package is true complete and correct and ii I agree that If any information contained in my application package is false or misleading or if any relevant information has been concealed withheld or not submitted as part of my application package my application package may at the sole option and discretion of Alberta Health Services be rejected from eligibility or If I have already commenced an ACSAP program my admission and enrolment may at the sole option and discretion of the Program Medical Director be cancelled or revoked and iii I will share the applicable documents with ACSAP via physiciansapply. ca prior to submitting my application and iv All decisions made by Alberta Health Services are final and cannot be challenged. Date Signature Print Name PART E MANDATORY REQUIREMENTS CHECKLISTS Use this checklist to ensure that your application package is complete. Document must be a photocopy of an original certified copy. Canadian Birth Certificate Canadian Citizenship Certificate Canadian Passport Permanent Resident Card Canadian Work Permit Official English Language Test Results circle one.