CIED Certification Application
Personal Details
Name
*
First Name
Last Name
Work Email
*
Phone Number
*
Current CV
*
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Please attach your CV
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Employment Details
Position Title
*
Employer/Hospital
*
Are you employed full time or part time?
*
Full Time
Part Time
Years of Experience in a Cardiology Related Field
*
Roughly what percentage of your time is spent in CIED follow-up?
*
Where are you applying from?
*
Please Select
New Zealand
Australia
When do you plan to sit IBHRE?
Which state are you applying from?
*
Please Select
New South Wales
Queensland
South Australia
Tasmania
Victoria
Western Australia
Australian Capital Territory
Northern Territory
Which city will you be working in?
*
CIED Supervisor
Your supervisor will be contacted regarding your application.
CIED Supervisors Email
*
Supporting Letter
*
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Please attach a letter from your supervisor to confirm your employment to support your application to the course.
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Professional Registration
Are you a current SCT financial member?
*
Yes
No
Are you a current PICSA financial member?
*
Yes
No
CPRB Registration Number
*
Do you have a current APC?
*
Yes
No
Please upload your Registration & APC
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Qualifications
CCP Completion Date
*
/
Day
/
Month
Year
Date
MTEX Completion Date
*
/
Day
/
Month
Year
The date the diploma was awarded
BSc Completion Date
*
/
Day
/
Month
Year
Date
What is your Post-Grad Qualification?
*
Post-Graduate Qualification Completion Date
*
/
Day
/
Month
Year
Date
Qualifications
*
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Please upload evidence of your relevant qualifications (BSc/Post-Graduate Diploma/Masters). If you are a NZ applicant, please include evidence of MTEC and CCP completion.
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Submit
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