Program Request for Waiver or Deferral

Program Request

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:

NRMP Program Code(Required)

NRMP ID

The applicant’s NRMP ID if known.

Specialty(Required)

Institution(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Program Director Name(Required)

Prefix First Last

Program Director Email(Required)

If your program does not have a program coordinator, please enter the program director’s information again.

Program Coordinator Name(Required)

Prefix First Last

Program Coordinator Email(Required)

Institutional Official Name(Required)

Prefix First Last

Institutional Official Email(Required)

Who is filling out this request?(Required)

Select One

Who is the primary contact for this request?(Required)

Select One

In which Match does the program participate?(Required)

Select One

Which Fellowship Match is the program a part of?(Required)

Select One

Please provide information about your matched applicant:

Applicant Name(Required)

First Last

Applicant Email(Required)

Applicant AAMC ID(Required)

Applicant Start Date(Required)

Tell us about your request:

Is the program requesting a waiver or deferral?(Required)

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?(Required)

Why is the program requesting a deferral?(Required)

Please provide an explanation for the request:(Required)

Please include all relevant information, context, and applicable timelines necessary for the NRMP to understand the situation.

If the waiver is denied, will you honor your binding commitment regardless of the NRMP's decision?(Required)

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)(Required)

You have notified the matched applicant(s) of the waiver/deferral request.

Contact of Relevant Parties(Required)

The NRMP will review your request and contact your matched applicant(s) and all relevant parties.

Responsibility to Match Commitment during Waiver/Deferral Process(Required)

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(Required)

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(Required)

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.

Signature

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.

CAPTCHA

Please upload documentation to support your request – 3 file maximum

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Once the NRMP receives your request, you will have the opportunity to submit additional documentation if necessary.

Please review all information carefully before submitting your request.

Comments

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