Program Request for Waiver or Deferral

Program Request for Waiver or Deferral
NOTE: You are required to notify the matched applicant of the request and the rationale. If you have not yet done so, STOP and inform your matched applicant(s) that you will be submitting a request.
Please provide information about the program:

* indicates required field.
NRMP Program Code *
(e.g. 1234567C0)
Specialty *
(e.g. Internal Medicine, Dermatology, Pediatrics, etc.)
Institution *
(e.g. UT Southwestern, SUNY Downstate, University of Arizona - Tucson, etc.)
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Program Director First Name *
First Name
Program Director Last Name *
Last Name
Program Director Title *
Select One
Program Director Email *
example@example.com
Program Coordinator First Name *
First Name
Program Coordinator Last Name *
Last Name
Program Coordinator Title *
Select One
Program Coordinator Email *
example@example.com
If your program does not have a program coordinator, please enter the program director's information again.
Institutional Official First Name *
First Name
Institutional Official Last Name *
Last Name
Institutional Official Title *
Institutional Official Email *
example@example.com
Who is filling out this request? *
Select One
Who is the primary contact for this request? *
Select One
In which Match does the program participate? *
Select One
Which Fellowship Match is the program a part of? *
Select One
Please provide information about your matched applicant:
Applicant First Name *
First Name
Applicant Last Name *
Last Name
Applicant Email Address *
example@example.com
Applicant AAMC ID *
(e.g. 12345678)
Applicant Start Date *

Month Day Year
Date
Tell us about your request:
Is the program requesting a waiver or deferral? *
A waiver releases the program and the applicant from the binding match commitment; a deferral is a one-year delayed start of training. A deferral must be agreed to by both parties.
Why is the program requesting a waiver? *
Select One
Why is the program requesting a deferral? *
Select One
Is this related to the applicant's inability to obtain a Statement of Need? *
Select One
What is the Applicant's Country of Citizenship? *
Select One
Please provide an explanation for the request: *
Please include all relevant information, context, and applicable timelines necessary for the NRMP to understand the situation.
Please describe how you will assist each applicant in securing another training position: *
If the waiver is denied, will you honor your binding commitment? *
PLEASE NOTE: Choosing "NO" indicates that you will not honor the binding commitment regardless of the waiver outcome. Once confirmed, the NRMP will release the matched program from the match commitment and continue separately with your waiver.
Terms and Conditions for NRMP Waiver/Deferral Request

By checking, you agree to the following:
Communication with Matched Applicant(s) *

You have notified the matched applicant(s) of the waiver/deferral request.
Contact of Relevant Parties *

The NRMP will review your request and contact your matched applicant(s) and all relevant parties.
Responsibility to Match Commitment during Waiver/Deferral Process *

While the waiver/deferral request is under review, the program may not seek a new applicant; or discuss the position, interview, or offer the position to another applicant. Doing so may result in a violation investigation.
Potential Outcome of Waiver/Deferral Process *

If the waiver/deferral is not granted, the program will be expected to honor the match commitment. Failure to do so may result in a violation investigation.
NRMP Decision of Waiver/Deferral *

NRMP has sole discretion to grant or deny a requested waiver or deferral. NRMP’s decision is final and is not subject to challenge in arbitration, by judicial review, or by review of a third party.
By submitting this form, you are confirming that you wish to move forward with the waiver/deferral process. The NRMP will begin processing your request. *

Clear
Please verify *
Please upload documentation to support your request - 3 file maximum

Once the NRMP receives your request, you will have the opportunity to submit additional documentation if necessary.
Cancel of
Please review all information carefully before submitting your request.
Should be Empty:

Program Request for Waiver or Deferral

Please provide information about the program:

Please provide information about your matched applicant:

Tell us about your request:

Terms and Conditions for NRMP Waiver/Deferral Request