Application for Spirometry Certification Examination

APPLICATION FOR SPIROMETRY CERTIFICATION EXAMINATION
• Please refer to Eligibility Criteria and Registration Process for Spirometry Certification for complete details on how to apply and examination details.
• After submitting the Application Form, you will be directed to the Shop page to make payment for the application.
Note: This application will not be reviewed until all necessary documentation has been received and fees paid. Up to 4 weeks are needed to review all documentation.
Section I: Personal Information
Name

First NameLast Name
EDUCATION/CREDENTIALS

Other
Gender
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Contact Phone Number

Area CodePhone Number
Email
example@example.com
Section II: Workplace Information
Institution Name:
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Telephone Number

Area CodePhone Number
Position Held
Length of Employment
Years
.
Months
Name of Immediate Supervisor:
(First, Last)
Email Address of Supervisor:
example@example.com
Brief Description of Responsibilities
Percent of time in:
Patient Care
Percent of time in:
Technical (Spirometry Testing)
Percent of time in:
Research
Section III: Spirometry Testing Experience
A) Have you taken any CACPT approved Spirometry courses within 36 months? See Candidate Guide to Spirometry for a list of approved courses.
If "yes", please provide the following information:
Course Name:
Institution Name:
Date Completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Note: You do not need to complete Section B and you do not need to submit any Spirometry Examples if you have completed an approved course.
B) If "no", please provide the following information for Spirometry Testing on site training.
Institution Name:
Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Training Date
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Preceptor:

First NameLast Name
Professional Organization of Preceptor:
Registration Number of Preceptor:
Credential(s) of Preceptor:
Other
Seven Spirometry Examples with supporting data are required if the applicant has not completed a Spirometry Course within 36 months. See “Spirometry Examples Requirement”
I,
applicant,
certify that,
Upon submitting this application you will automatically be directed to the shop page to make the non-refundable fee(s) payment of $30.00.
Address for mailing of required documents if necessary

CACPT

Gabriela Rodriguez
Education Chair
Mount Sinai Hospital
600 University Avenue,
4th floor, Room 474
Toronto, Ontario M5G 1X5
Enter the message as it's shown
For more information contact spirometry@cacpt.ca
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APPLICATION FOR SPIROMETRY CERTIFICATION EXAMINATION