**The Department/Division is responsible for obtaining licensure Application Type from the College of Physicians and Surgeons of British Columbia, as well as confirming that the Postgraduate (Clinical) Fellow has Postgraduate (Fellow) appropriate personal medical malpractice insurance and Postgraduate (Fellow) with SEAP immigration/work permit documentation. SEAP must be Request for Extension < 6 months declared at time of application ** Request for Extension > 6 months Department/Division Contact Information Name: Address: Number: Applicant Information Last Name: Name: Name (if different on medical degree): M F Date of Birth (m/d/yy): Country of Birth: Citizenship: Permanent Resident (Landed) Work Permit Email Address: Street Address: City/Province: Postal Code: Cell Phone: Email: Medical Degree Information University/College Name: Medical Degree: Date: Country: Medical Council of Canada Examinations MCCEE: Date: MCCQE Part I: Date: LMCC#: Date:
Application Type **The Department/Division is responsible for obtaining licensure from the College of Physicians and Surgeons of British Columbia, as well as confirming that the Postgraduate (Clinical) Fellow has appropriate personal medical malpractice insurance and immigration/work permit documentation. SEAP must be declared at time of application ** Postgraduate (Fellow) Postgraduate (Fellow) with SEAP Request for Extension < 6 months Request for Extension > 6 months Department/Division Contact Information Name: Address: Number: Applicant Information Last Name: Name: Name (if different on medical degree): M F Date of Birth (m/d/yy): Country of Birth: Citizenship: Permanent Resident (Landed) Work Permit Email Address: Street Address: City/Province: Postal Code: Cell Phone: Email: Medical Degree Information University/College Name: Medical Degree: Date: Country: Medical Council of Canada Examinations MCCEE: Date: MCCQE Part I: Date: LMCC#: Date: