fcai written exam application
TRANSCRIPT
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7/25/2019 FCAI Written Exam Application
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Application for the Final Written Examination for the Fellowship of
The College of Anaesthetists of Ireland (F.C.A.I)
Day Month Year
Date of Intended Exam: College ID:
Surname
First name
Day Month Year
Date of Birth Gender Nationality
Email
Correspondene !ddress Mo"ile or #elephone
Name of "ody $ith $hom you
o"tained medial registration e%g
Irish Medial Counil
&egistration Num"er
'rimary Medial (uali)ation
Year
Country $here *uali)ation $as a$arded
'lease list any attempts at the Final F&C! of the &C+! "elo$
1. 3. .
!. ". #.
,
!ttah
, photo
here
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I passed the C!I 'rimary -Mem"ership examination on:
or the
follo$ing exempting *uali)ation from the urrent examination regulations%
'lease ti. /
#he 'rimary or Final Fello$ship of the &oyal College of !naesthetists 0123#he Fello$ship of the !ustralian and Ne$ 4ealand College of !naesthetists#he Fello$ship of the College of !naesthetists of South !fria#he Fello$ship in !naesthesia of the &oyal College of 'hysiians andSurgeons of Canada
#he Diplomate Certi)ate of the !merian Board of !nesthesiology#he Diploma in !naesthesiology of the European Soiety of !naesthesiology
#he Fello$ship in !naesthesiology of the College of 'hysiians and Surgeons'a.istan sine !pril ,556+7erseas (ualifying Examination of the College of !naesthetists of Ireland
$lease attach photocopies of exempting %&ali'cations signed as
tr&e copies the cons<ant that signs the application form.
!re you in a training programme8 Yes No 'lease name the "ody
responsi"le for the programme and the grade or title of the post% e%g C!I S!#
9
Emploment *istor+ $lease list 3# months of emploment in
anaesthetic posts in chronological order starting with o&r c&rrent
post.
Grade or title of
post
ospital Name 0Country3 From 0date3 #o 0date3
Signature of Exam Candidate
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Signature of ead of Department
'rint Name of ead of Department
Date ospital
$A,-ET /ETAI0 FIA0 FE002W*I$ C200EE I/
Candidates Full Name
Che*ue< "an. draft or money order attahed 24 redit ard
0'aya"le to C!I3
C&EDI# C!&D N1MBE& =IS! =IS! DEBI#
M!S#E&C!&D
> > >
E?'I&Y MM-YY Seurity ode
!mount @AName on ard 0"lo. letters3
Cardholders signature
Send the ompleted form together $ith the full amount of the fee to:
College of !naesthetists of Ireland
Examinations Department
;; Merrion S*uare North
Du"lin ;
Ireland
Email: examsoa%ie
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