fcai written exam application

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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&ltant 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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