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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NZQA Details
Have you completed any NZQA approved qualifications (including schooling) in NZ in the past?

YesNo
National Student Number
If you do not have an NSN, SCT will apply for you to be allocated one.

If you are unsure of your NSN, instructions to find it can be found here.
Should be Empty:

CIED Certification Application

Personal Details

Employment Details

Professional Registration

Qualifications

NZQA Details