GME Verification Request Form

For trainees whose last day at Virginia Mason Franciscan Health was less than two years ago.

Please complete the below fields.

* Indicates required information
Name during Training - Last: *
Name during Training - Last:  Alternate Last Name
Name during Training - First: *
Programs: *  (check at least one box, may click more than one)	Anesthesiology Complex Spine Digestive Disease Facial Plastics Family Medicine Female Pelvic Medicine Foot and Ankle Sports Medicine General Surgery Gynecology Internal Medicine Minimally Invasive Gynecological Surgery Neurosurgery Pain Medicine Plastic/Reconstructive Surgery Podiatry/Sports Medicine Radiology Regional Anesthesiology Transitional Year Urology
Year of Graduation: *	Select one 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970
Program Director Name:
FOR BOARD CERTIFICATION OR STATE LICENSURE Please attach Release of Information with hand-written signature of graduate along with additional required documentation you may require. FOR EMPLOYMENT VERIFICATIONS FOR ORGANIZATIONS OTHER THAN BOARDS/LICENSURE: Please attach ONLY release of information with hand-written signature of graduate. VIRGINIA MASON FRANCISCAN HEALTH provides a standard verification form. DO NOT UPLOAD YOUR ORGANIZATION'S FORMS FOR COMPLETION.
Upload PDF file: *  (All documents in a single PDF file)
Email address for return of verification: *