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*

BScMScRNNPOther
Gender

MaleFemaleN/A
Date Of Birth

MonthDayYear
Date
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.
YesNo
If "yes", please provide the following information:
Course Name:
Institution Name:
Date Completed

MonthDayYear
Date
Proof of completion is attachedProof of completion mailed to address listed at end of applicaton.
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.
Same as Workplace information aboveOther Institution
Institution Name:
Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Training Date
Date Started

MonthDayYear
Date
Date Completed

MonthDayYear
Date
Name of Preceptor:

First NameLast Name
Professional Organization of Preceptor:
Registration Number of Preceptor:
Credential(s) of Preceptor:

MD with Spirometry experienceRegistered Technologist of CACPT in PulmonaryRRT currently active in Spirometry TestingAllied Health Professional, (please check one) currently active in Spirometry Testing. If "other" please specify:
RNRPNNPPharmacistOther
Seven Spirometry Examples with supporting data are required if the applicant has not completed a Spirometry Course within 36 months. See “Spirometry Examples Requirement”
Spirometry Examples with supporting data are attachedSpirometry Examples to be mailed to address at end of applicationContact spirometry@cacpt.ca to arrange method of providing Spirometry Examples
I, *
applicant,
certify that,*

I received appropriate training by the preceptor named in this applicationI performed the Spirometry Examples provided in this application (If applicable)I certify that all the information provided in this application is accurate and true
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

C/O Laura Seed

40-561 Childs Dr.

Milton, ON

L9T 3Z1
Enter the message as it's shown*
For more information contact spirometry@cacpt.ca
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APPLICATION FOR SPIROMETRY CERTIFICATION EXAMINATION