Department(s)/Division(s)

PART TWO:

PART THREE:

CONTINUING MEDICAL EDUCTIONAL PROGRAMS AND CERTIFICATION UPDATES:

PART FOUR:

LIABILITY INSURANCE:

PART FIVE:

If Yes, please complete the section below

PART SIX:

If the answer to any part of the following questions is true, please provide a written statement describing details and append it to this application.

PART SEVEN:

PART EIGHT:

I hereby affirm that I have read the Public Hospitals Act, the Hospital Management Regulation thereunder, the Health Care Professional Staff Bylaws and General Rules & Regulations. I understand that if appointed to the Professional Staff, I will provide the services to the Hospital as stipulated in this application, and will govern myself in accordance with the requirements set out in the Public Hospitals Act, other relevant Acts, the Health Care Professional Staff Bylaws, General Rules & Regulations and policies. I acknowledge that failure to provide the said services constitutes a breach of my duties, and that the Hospital may, upon consideration of the individual circumstances, remove my access to any and all Hospital resources, including the limiting or restricting of operating room time, or take such action as is reasonable, in accordance with the Professional Staff Bylaws and General Rules & Regulations. I acknowledge that the Hospital may refuse to appoint me to the Professional Staff if I refuse to acknowledge the responsibility to abide by a commitment to provide services in accordance with the Privileges granted by the Board, and in accordance with the Health Care Professional Staff Bylaws, General Rules & Regulations and policies.