Original Certificates Online Payment Form

Original Certificates Online Payment Form

Please read the instructions below carefully prior to completing the accompanying form.
INSTRUCTIONS

Please ensure to send inquiries and requests to the appropriate point of contact before you proceed to complete this form. The point person will first confirm the trainee was in fact registered with the Department of Medicine, University of Toronto, and will then provide the appropriate information on how to obtain the training certificate(s):
- Request for Residency Certificate(s) – Residency Coordinator at medicine.training@utoronto.ca
- Request for Fellowship Certificate(s) – Fellowship Coordinator at fellowships.medicine@utoronto.ca
This online payment form is to be used by physicians (residents, and clinical and research fellows) who have not obtained their certificate in-person and is requesting for their certificate to be mailed, and the Residency/Fellowship Coordinator has confirmed the certificate is held within the Department of Medicine.
- Please note that Department of Medicine will hold certificates for two (2) calendar years from the date of your training completion date. Outside of this timeframe, you must request for a replacement certificate.
Important Notes:
- Processing Time: Upon receipt of all the necessary information and payment, the request will be finalized within 15 business days
- Refund Policy: In the event we are unable to mail out the certificate and will need to direct the trainee to the Postgraduate Medical Education (PGME) office for the request, the full refund will be issued as a cheque that will be mailed out, which may take up to 6-8 weeks. Otherwise, all payments are final and no refund will be issued.
For detailed information, please refer to the Department of Medicine Certificate Process.
Statement of Obligation
In accordance with the University of Toronto’s Department of Medicine policy, Certification of Training will not be released for trainees/alumni with outstanding administrative requirements and/or financial obligations of the training program and Postgraduate Medical Education (PGME) to the University. Requests will not be processed until the administrative and/or financial hold is cleared and removed from the record.
By proceeding to complete the Certificates Online Payment Form, I hereby agree to the following:*

I acknowledge I have carefully read and fully understand the contents of the aforementioned Instructions AND the hyperlinked Department of Medicine Certificate ProcessI acknowledge I have contacted the appropriate Coordinator and they have confirmed with me that I was in fact registered with the Department of Medicine, University of Toronto, and has directed me to this website to proceed with the Certificates Online Payment FormI understand that all outstanding requirements and financial obligations must be cleared in order to receive my certificate(s)

Personal Information
Physician's Name*

First NameLast Name
Additional or Former Name (if applicable)
Date of Birth*

YearMonthDay
Date
Contact Email Address*
example@example.com
Contact Telephone Number*

Original Certificate Request(s)

You may request up to three (3) certificates.
Please indicate the number of Original Certificate request(s)*
Original Certificate Request #1
Training Level*
Year of Training Completion*
Division Name*
Subprogram Name if applicable (ie. Fellowship Title)
Original Certificate Request #2
Training Level*
Year of Training Completion*
Division Name*
Subprogram Name if applicable (ie. Fellowship Title)
Original Certificate Request #3
Training Level*
Year of Training Completion*
Division Name*
Subprogram Name if applicable (ie. Fellowship Title)
Original Certificate Request #4
Training Level*
Year of Training Completion*
Division Name*
Subprogram Name if applicable (ie. Fellowship Title)
Delivery Options

If you are requesting a certificate for more than one type of training, please consider providing information for all of them in this one (1) single request form for the purpose of shipping consolidation (ie. to avoid additional delivery costs).
Please select the method to obtain the certificate(s)*

In-Personvia Mail

Shipping Mailing Address Information

Other than original certificates that have met the retention policy and are readily available in the Department of Medicine for pickup, please note that there is a cost associated with delivering all other certificates. This will be an additional cost on top of certificate production.
Mailing Destination*

Priority mail within Greater Toronto Area ($35.00 CAD)Priority mail within Ontario ($40.00 CAD)Priority mail within Canada (outside of Ontario) ($50.00 CAD)Priority mail to the United States of America ($60.00 CAD)Priority mail to an international destination ($125.00 CAD)
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Online Payment Information
Total amount of payment will be (Canadian dollars):
What type of Trainings are included in the selections?
Billing address same as shipping address?*

YesNo
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Credit Card Details*

CADTotal amount of payment (Canadian dollars)

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

The Department of Medicine has partnered with Moneris (service provider) to provide clients with an online credit card fee payment option.

The online Mastercard and Visa Canadian Dollar verification fee payment service is inclusive of a convenience fee collected directly by Moneris.
Acknowledgement
By signing below, I declare that the information I have given in this form is accurate and true, and I acknowledge that my payment and order is final.
Signature*

Clear
Date signed*

YearMonthDay
Date
Freedom of Information and Protection of Privacy: The University of Toronto is committed to the protection of privacy. Ontario universities are covered by the Freedom of Information and Protection of Privacy Act (the Act) which supports access to University records and protection of privacy. The University upholds these principles. For detailed information and its application, please visit https://www.utoronto.ca/privacy.
Should be Empty:

Original Certificates Online Payment Form

Statement of Obligation

Personal Information

Original Certificate Request(s)

Original Certificate Request #1

Original Certificate Request #2

Original Certificate Request #3

Original Certificate Request #4

Delivery Options

Shipping Mailing Address Information

Online Payment Information

Acknowledgement