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Residency Program Selection Application Form

This is to be completed in CAPITAL LETTERS
Personal Information
Name (as in passport)

____________________

___________________________

__________________________

First Name

Middle Name

Family Name

Date of Birth: _______________

Place of Birth: ______________________________________

Nationality: ________________

(dd/mm/yyyy)

Gender:

Male

Female

Mailing Address: ____________________________________

Passport No.: _______________________________________

Marital Status:

Single

Married

e-mail address: __________________________________________

Expiry Date: _____________________________________________
(dd/mm/yyyy)

Telephone Number: ________________________ Mobile Number: _________________________

Fax Number: _______________

Education
Name of Medical College:

___________________________________________

Date of Graduation:

___________________________________________

Country: ____________________________

(dd/mm/yyyy)

Language used in Medical College:

English

Arabic

Other (please specify) _____________________

Internship (First year Post-Graduate Training or Practise)

Rotating Internship

HMC

Others: (Please specify) ________________________________________

Straight Internship (First Year Post-Graduate Training or Practise)

Institution Name: ____________________________________

Country: ___________________________________________________

Dates: (from) _________________________________________

(to) _________________________________________________________

(dd/mm/yyyy)

(dd/mm/yyyy)

Qualifying Examinations Results

Examinations

3-Digit Score

2-Digit Score

Date (dd/mm/yyyy)

Score

Date Taken (dd/mm/yyyy)

USMLE Step 1
USMLE Step 2 CK (Clinical Knowledge)
USMLE Step 2 CS (Clinical Skills)
USMLE Step 3
IFOM CSE

English Language Proficiency Test

Examinations
IELTS
TOEFL
IBT
CBT
PBT

No. of Attempts

Language Competencies

Arabic

English

Other Languages

Spoken

Fluent

Fluent

Fluent

Average

Average

Average

Below Average

Below Average

Below Average

Fluent

Fluent

Fluent

Average

Average

Average

Below Average

Below Average

Below Average

Written

Statement of Verification

I, Dr. ______________________________, acknowledge that all information provided in this application are
true and all documents are authenticated. I authorize Hamad Medical Corporation (HMC) to seek
verification of any, and all, of those documents and any relevant information. I understand that in the case
HMC finds any information or documents are false, HMC has the right to terminate my contract.

Signature ______________________________
Date: __________________________________
For GME Use Only

Complete Application Form should include the following documents 3 sets of documents but only one
Residency Application and one Matching Form

Updated CV
Letter of Intention (see FAQ for details)
Passport copy
Residency permit copy (if resident in Qatar)
Internship Certificate copy
Medical Degree (Certificate copy)

Received by:

Matching Application Form

USMLE Step 1 Results
USMLE Step 2 CK Results OR
IFOM Results
TOEFL or IELTS Results
8 Photos (Recent Passport Size with white background)

Signature:

Date:

Approved

Not Approved Reasons: ____________________________________________________________________

Deputy Chief of Staff for Medical Education: _____________________________________________________

Signature: ____________________________________________________ Date: _________________________

Revised: MEdEduc Dadish2082