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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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