2015 final examination application form
Transcription
2015 final examination application form
ABN 82 055 042 852 AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS Training FEX Final Examination Form 1. FINAL EXAM REQUIREMENTS Advanced Trainees applying for admission to the Final Examination must, by the application closing date, have submitted documentation to validate that they have, by the date of the written section of the Final Examination (Regulation 14.5.1) Completed PMET, Basic Training, and ATY1 (Reg. 14.5.1.1) Completed 104 weeks of Clinical Training in Clinical Anaesthesia (Reg. 14.5.1.2) Passed the Primary Examination or have been granted exemption (Reg. 14.5.1.3). Please ensure that the college has received all required documentation and pay all outstanding training fees. 2. PERSONAL INFORMATION ANZCA ID: Family Name: Date of Birth: First name: Middle Name: Day Month Year 3. CONTACT INFORMATION Postal Address: Suburb/City:State: Postcode:Country: Mobile Phone: Country Local Other Phone: Country Area Local Email Address: 4. EXAM DATE AND VENUE Please select which examination sitting you will attend, and then your preferred venue for the Written and Medical sections of the examination. Please tick the preferred venue for the 1st Sitting 2nd Sitting Written and Medical sections of the examination. Written & Medical Written & Medical 20 & 21 March 21 & 22 August Adelaide Sydney Oral (in Melbourne only) 22 & 23 May Oral (in Sydney only) 23 & 24 October Brisbane New Zealand Melbourne Hong Kong Perth 18 November 2014 PAGE 1 OF 3 AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS ANZCA ID: 5. DECLARATION I certify that: a) I have no illness or disability that would preclude the safe practice of anaesthesia, intensive care medicine and pain medicine, including dependence on or inappropriate use of alcohol or recreational and/or non-prescribed drugs, and/ or treatment with prescribed drugs likely to compromise the safe practice of anaesthesia, intensive care medicine or pain medicine. or I have informed the College of any illness or disability that would preclude the safe practice of anaesthesia, intensive care medicine and pain medicine, including dependence on or inappropriate use of alcohol or recreational and/or non-prescribed drugs, and/or treatment with prescribed drugs likely to compromise the safe practice of anaesthesia, intensive care medicine or pain medicine, and I am receiving appropriate medical care. and b) I undertake to notify the College if I develop an illness or disability that would preclude the safe practice of anaesthesia, intensive care medicine and pain medicine, including dependence on or inappropriate use of alcohol or recreational and/or non-prescribed drugs, and/or treatment with prescribed drugs likely to compromise the safe practice of anaesthesia, intensive care medicine or pain medicine. Signature: Date: Day Month Year 6. PAYMENT DETAILS Australia AUD $5353.00 Hong Kong, Malaysia and Singapore AUD $5342.00 New Zealand NZD $7772.00 Includes 15% GST Cheque, Bank Draft or Money Order attached (Payable to ANZCA and crossed “Not Negotiable”.) Credit Card (please tick one) Credit Card Number: Name on Card: Expiry Date: Cardholder’s signature Send the completed form together with the full amount of the fee to: ANZCA c/o Exams Unit PO Box 6095 MELBOURNE VIC 3004 AUSTRALIA Fax: +61 3 9510 6786 Email: [email protected] Please note: Only credit card payments will be accepted by fax or email. Please see Section 5 of the notes. 18 November 2014 PAGE 2 OF 3 AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS Final Examination Form (Notes) FIRST SITTING SECOND SITTING 20 & 21 March (Closing date 13 January) 21 & 22 August (Closing date 8 June) Written & Medical Examination Dates Oral Examination Dates and Venues 22 & 23 May (in Melbourne only) Written & Medical Examination Dates Oral Examination Dates and Venues 23 & 24 October (in Sydney only) Applications and/or associated documentation will not be accepted after the closing date. Withdrawal fees apply to candidates who withdraw from the exam as per Regulation 14.7.3. Eligibility for Final Examination To sit the Final Examination, you must have submitted documentation to validate that you have, by the date of the Written and Medical sections of the Final Examination: • Completed PMET, Basic Training and ATY1 • Completed 104 weeks of Clinical Training in Anaesthesia • Passed the Primary Examination or have been granted exemption • Paid all outstanding fees • Submitted all Outstanding documentation These eligibility requirements must be met by the date of the Written and Medical sections of the examination. See Regulation 14 for further details on the Final Examination. Instructions for Completing the Final Examination Form (FEX) 2. Personal Information ANZCA Trainee ID: If you have not yet registered or cannot locate your ID, contact the Training & Assessments Unit on +61 3 9510 6299. 4. Exam Date and Venue The Final Examination is held twice a year with each sitting comprising a Written and Medical section and an Oral section. You must select (i) which sitting you will attend, and (ii) where you will present for your Medical and Written sections. 5. Declaration The College requires that you sign this statement stating that you do not have a dependency on recreational and/or non-prescribed drugs. 6. Payment Details Cheque: If you are paying by cheque it must be drawn on an Australian bank in Australian dollars and made payable to ANZCA. Bank Draft or Money Order: These can be drawn by any international commercial or postal bank, but must be denominated in Australian dollars. They should be made payable to ANZCA. Cardholder’s Signature: If you are paying by credit card, please ensure that you authorise your payment with your signature. First Name: If your first name is hyphenated or two words, e.g., Wu Xiao Ping, Anne-Marie Jones, enter this in the first name box. 3. Contact Information Address, Phone and Fax Numbers: Please give your country and area or city codes, in addition to your local number. If you do not have an area or city code, e.g., Hong Kong or Singapore applicants, leave this space blank. Kindly advise the Final Exam Officer by email ([email protected]) if any of these details change during the course of the exam. 18 November 2014 PAGE 3 OF 3