AA Certificate Application
First name
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Last name
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E-mail
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Address
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City
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Province
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Postal code
Phone Number
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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.
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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.
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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.
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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
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Month
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Day
Year
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.).
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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:
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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
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Month
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Day
Year
Type your full name as signature
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Submit
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