CIED Certification Application

CIED Certification Application
Personal Details
Name*

First NameLast Name
Work Email*
Phone Number*
Current CV*

Please attach your CV
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Employment Details
Position Title*
Employer/Hospital*
Are you employed full time or part time?*

Full TimePart 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? *
When do you plan to sit IBHRE?
Which state are you applying from?*
Which city will you be working in?*
CIED Supervisor
Your supervisor will be contacted regarding your application.
CIED Supervisors Email*
The invoice will be sent to the Charge Physiologist/Supervisor you have entered in the employment information section. Please ensure this has been discussed prior to submission.
Supporting Letter*

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?*

YesNo
Are you a current PICSA financial member?*

YesNo
CPRB Registration Number*
Do you have a current APC?*

YesNo
Please upload your Registration & APC

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Qualifications
CCP Completion Date*

DayMonthYear
Date
MTEX Completion Date*

DayMonthYear
The date the diploma was awarded
BSc Completion Date*

DayMonthYear
Date
What is your Post-Grad Qualification?*
Post-Graduate Qualification Completion Date*

DayMonthYear
Date
Qualifications*

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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CIED Certification Application

Personal Details

Employment Details

Professional Registration

Qualifications