UGME Member Profile Form

The academic leadership of the Undergraduate medical education program extend a heartfelt appreciation for your dedication and hard work in educating our students. Your commitment to excellence in teaching does not go unnoticed.

Instructions:

All fields are mandatory and must be completed prior to submitting the form.

Last Name:

First Surname:

U. of Ottawa Employee #: (if known)

E-mail Address:

Home Address: (no business address)

Address:

City:

Province:

Postal Code:

Home Telephone Number:

Select "Home" Type

Mobile Telephone Number:

Select "Cell" Type

Work Telephone Number:

Select "Office" Type

Residency Status:

Canadian Citizen

Visa

Permanent Resident

Profession/Occupation:

Hospital Affiliation:

Department:

Division:

Write "Not applicable" if no division

Payment Information

Payment Method:

If you are eligible for remuneration, select one method of payment. Please note: Remuneration for resident is paid to the Department.

Individual

(provide payment information by creating your Workday supplier account)

Corporation

(provide payment information by creating your Workday supplier account)

Department/PracticePlan

(payment information to be provided by department)

Do Not Pay

Name of Corporation

If you make any modifications to your profile (banking information; individual vs corporation; HST etc..), please notify us immediately by email at [email protected].

Payment to individual or corporation

HST registered?

Yes

If yes, please provide vendor Business number :

To process your payment, you will need to create your Workday supplier account.

Please follow the instructions included on the Supplier Registration webpage north east external link.

If you need assistance in creating your supplier account, please contact [email protected] and we will be happy to assist you by phone or in person.

Payment to Department/Practice Plan

Payment information will be provided by your department.

Please do not hesitate to reach out to us if you have any questions at [email protected].

AUTHORIZATION

Signature

Sign above

Date