Ama Physician Locum Services Rural Locum Program Application Form
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2T 780.482.2626
F 780.732.3361
12230 106 Ave NW
Edmonton AB T5N 3Z1
TF 1.800.272.9680
Rural Locum Program
AMA PHYSICIAN LOCUM SERVICES
RURAL LOCUM PROGRAM APPLICATION FORM
please type or print
Surname
___________________________________________________________________
Given name(s)
___________________________________________________________________
Residence address
___________________________________________________________________
___________________________________________________________________
Professional/alternate
___________________________________________________________________
address
___________________________________________________________________
Residence telephone (
) ___________________
Business telephone (
) _____________________
Fax (
) ______________________
Email address _______________________________
PRAC ID#: _______________________________
AMA Member: Yes
No
Are you a Canadian Citizen or Permanent Resident of Canada?
Yes
No
If you answered No, are you eligible to work in Canada?
Yes
No
Please provide a copy of your valid work permit and state the expiry date: _____________________
Application for: Regular locum program ________ Weekend locum coverage: ________
Proposed starting date of applicant's contract with the AMA Physician Locum Services ______________
References (please include three professional references, one of which must be either your preceptor/program
director, chief of staff of your hospital or regional medical director of the regional health authority in which you
work):
(1)
(2)
(3)
_______________________________
_______________________________
_______________________________
name
name
name
________________________________
________________________________
________________________________
address
address
address
________________________________
________________________________
________________________________
city/province
city/province
city/province
________________________________
________________________________
________________________________
postal code
postal code
postal code
_______________________________
_______________________________
_______________________________
telephone
telephone
telephone
_______________________________
_______________________________
_______________________________
fax
fax
fax
_______________________________
_______________________________
_______________________________
email
email
email
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