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Scholars' Program Nomination Form - BIPOC Candidate (1)

 

Thank you for your interest in the Scholars' Program. Please fill out the required information below.

Ensure that all documents are submitted in PDF format and contain no special characters in the file name, including punctuation.

NOTE: This online form must be completed in one single session. This form cannot save your information to return to at a later time.

BIPOC Candidate (May Submit One)

Must be a Medical Student Y3-Y4 or Adult Program Resident PGY1-PGY2 or Pediatric Program Resident PGY1-PGY3.

Candidate must also be a CAG member or have applied to become one by October 21.

Please select one option
Please enter first name
Please enter last name
Please select one option
Please enter institution
Please enter street address
Please enter city
Please select a province
Please enter postal code
Please enter phone number
Please enter a valid email address
Please select one option

Note: Files must be in .PDF format.

In your Letter of Intent, please also include in your own words, how would you describe your racial or ethnic heritage as a BIPOC candidate.

Please upload a .PDF file with no special characters in file name
Please upload a .PDF file with no special characters in file name

Electronic Signature

By checking this box and typing my name, I certify that I am the person accessing this webpage, submitting this form and that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature.

 

I certify that the above information is true and correct and that I am the person completing this form.

*Only those who agree to the above may submit this form.
Please enter your full name.

Please ensure that all required fields are filled out correctly.

Upon successful submission, you will be redirected to a confirmation webpage and will receive an email from us. If this does not occur, please contact the CAG National Office.

NOTE: Do not close your browser or use the back button until redirected to the "Thank You" screen, confirming successful submission. Uploading large files may take a minute or so.