1. Have you ever been convicted of a criminal offence for which a pardon has not been granted? Yes* No 2. Have you ever been convicted of any other offence (for which a pardon has not been granted) Yes* No that may affect your eligibility for Ontario Educational registration (i.e. your eligibility for an educational license)? 3. Are there charges pending for an alleged offence that may affect your eligibility for Ontario Yes* No Educational registration? 4. Have you ever been subject to a disciplinary hearing of a medical licensing authority? Yes* No 5. Have you ever been denied licensure by a medical licensing authority or had such licensure Yes* No revoked or limited? 6. Have you ever been disciplined, suspended or dismissed from an undergraduate or postgraduate Yes* No educational program? 7. Has there been concern expressed regarding your undergraduate or postgraduate (including Yes* No fellowship training) ability or performance? Was any action taken because of this? Yes* No What was the outcome? * If you answered to any of the above, please provide details: “Yes” I hereby certify that the information given on this form and attachments is true and complete. I understand that I shall be disqualified if information is withheld or false information has been provided and that any appointment already made or in progress will be cancelled and all credit revoked. Date: Signature: Name (print): and when to submit your completed application and references: We are accepting applications for July 2019 as follows:
1. Have you ever been convicted of a criminal offence for which a pardon has not been granted? Yes* No 2. Have you ever been convicted of any other offence (for which a pardon has not been granted) that may affect your eligibility for Ontario Educational registration (i.e. your eligibility for an educational license)? Yes* No 3. Are there charges pending for an alleged offence that may affect your eligibility for Ontario Educational registration? Yes* No 4. Have you ever been subject to a disciplinary hearing of a medical licensing authority? Yes* No 5. Have you ever been denied licensure by a medical licensing authority or had such licensure revoked or limited? Yes* No 6. Have you ever been disciplined, suspended or dismissed from an undergraduate or postgraduate educational program? Yes* No 7. Has there been concern expressed regarding your undergraduate or postgraduate (including fellowship training) ability or performance? Was any action taken because of this? Yes* No What was the outcome? Yes* No * If you answered “Yes” to any of the above, please provide details: I hereby certify that the information given on this form and attachments is true and complete. I understand that I shall be disqualified if information is withheld or false information has been provided and that any appointment already made or in progress will be cancelled and all credit revoked. Date: Signature: Name (print): and when to submit your completed application and references: We are accepting applications for July 2019 as follows:
Pediatric%20Imaging%20Fellowship%20Application%20%28Rev%20April%2017%202017%29.docx