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:

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 file 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:

Please name the institution.

Year of Completion

2017 or before 2018 or after

Year of completion

Did you write the CCAA Exam?

Yes No

Date of Exam Completion

Date

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