Personal Information
First Name
This is required.
Last Name
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Pronouns (to support respectful and inclusive communication throughout the application process)
--None--
He/Him
She/Her
They/Them
Other
If any Other Pronoun, please specify
Preferred Name (if different from your legal or first name)
Do You Identify as Indigenous?
--None--
Yes
No
Salutation
--None--
Mr.
Ms.
Mrs.
Dr.
Prof.
Honorable
Other
If Other Salutation, please specify
Preferred Email (the email you check most often)
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Please enter a valid email.
Mobile
Work Phone
Preferred Method of Contact (communication is primarily conducted via email; please indicate any additional ways we may contact you, if needed)
--None--
Mobile
Work Phone
Assistant/MOA Name and Contact Information (if applicable):
Are you an MD or Healthcare Professional?
--None--
MD
Healthcare Professional Governed by the Health Professions Act
Healthcare Professional not Governed by the Health Professions Act
MD and Healthcare Professional
What is your Medical Services Plan (MSP) billing number (practitioner number)?
What is your registration number with your regulatory college?
What is your degree/specialty?
Primary Employer
What is your job/role title?
How does this role support the delivery of patient care?
Licensing/Registration/Professional Memberships (please check all that apply):
BC College of Registered Nurses and Midwives
BC College of Social Workers (BCCSW)
College of Family Physicians of Canada (CFPC)
College of Health and Care Professionals of BC (CHCPBC)
College of Physicians and Surgeons of BC (CPSBC)
Royal College of Physicians and Surgeons of Canada (RCPSC)
If any other provincial/territorial governing body, please specify
Faculty Appointment Information
Do you currently hold a Clinical Faculty appointment at another institution?
--None--
Yes
No
If yes, please specify the full name of the institution(s) where the appointment is held?
What rank is your Clinical Faculty appointment?
--None--
Clinical Instructor
Clinical Assistant Professor
Clinical Associate Professor
Clinical Professor
Other
If Clinical Faculty Appointment Rank is Other, please specify:
Do you currently hold an Academic Faculty appointment at a university or academic institution? (If yes, please specify the institution and your current academic rank.)
--None--
51猎奇入口 (SFU)
Other institution
If Academic Faculty Appointment is Other institution, please specify:
If you are a member of a Division of Family Practice (DoFP), which is your primary DoFP?
--None--
Abbotsford
Burnaby
Chilliwack
Delta
Fraser Northwest (FNW)
Langley
Mission
Ridge Meadows (RM)
Surrey North Delta (SND)
White Rock/ South Surrey (WRSS)
Other
If Primary Division of Family Practice is Other, please specify:
If you are not in a Division of Family Practice, which area do you primarily practice in?
Fraser North: Burnaby, New Westminster, Coquitlam, Port Coquitlam, Port Moody, Maple Ridge, Pitt Meadows, Anmore, Belcarra
Fraser South: Surrey, White Rock, Delta, Langley
Fraser East / Fraser Valley: Abbotsford, Chilliwack, Mission, Hope, Agassiz, Harrison Hot Springs, Kent
If Outside of Fraser region, please specify
Area(s) of Specialty Medicine:
In your family practice, do you have any focused areas of practice? (please select all that apply):
Addiction Medicine
Foundry
In-Patient Care
Long-Term Care
Maternity
Musculoskeletal
Skin Conditions
Urgent Primary Care Center
Women鈥檚 Health
If Other Focused Areas of Practice, please specify
I am interested in the following activities (please select all that apply):
Clinical Teaching 鈥� Outside of a clinical setting (e.g., clinical skills, small group, large group)
Clinical Teaching 鈥� Preceptor in a clinical setting (community-based or hospital)
Curriculum Development (e.g., case writing)
Program Leadership Roles (e.g., course director, course lead, site director, etc.)
Learner Mentorship and/or Participation in Career Exploration Sessions
Medical Research
If Interested in Other Activities, please specify
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