AA Certificate

First name *

Last name *

E-mail *

Address *

City *

Province *

Postal code

Phone Number *

- Area Code Phone Number

Please indicate your eligibility for the CCAA Certificate criteria:

Have obtained the appropriate RRT or RN professional designation from either the CSRT or the licensing body from a provincial jurisdiction. *

Yes No

I have obtained my RRT or RN designation from:

My registry number is:

I am a registered or an associate member in good standing with the CSRT. *

Yes No

I have been a registered member in good standing of the CSRT since (year)

My CSRT membership number is:

Have graduated from an anesthesia assistance program recognized by the CSRT OR have achieved equivalent clinical / professional experience (over 5 years) working exclusively in anesthesia. *

Yes No Have achieved equivalent clinical / professional experience (≥5 years) working exclusively in anesthesia

Graduated from the anesthesia assistance program at:

Year of completion

Employer

Number of years in active AA practice

Have been involved in professional development activities during the previous year (participation in workshops or RT-related conferences, participation on a committee or Board of either national or provincial RT professional organizations, participation on a local hospital professional committee or regional health planning board, etc.). *

Yes No

Please submit a list of education and professional development activities completed in the past 12 months (April 1 to March 31). You may also choose to upload any certificates.

Upload file (optional)

By submitting this application for the CCAA professional designation, I make a commitment to: *

Lifelong learning and maintaining involvement in professional development activities for a minimum of 25 hours per year (April 1 to March 31). Continue to be a registered (RRT) or an associate (RN) member in good standing with the Society.

Date *

- Month - Day Year

Type your full name as signature *

AA Certificate Application