2015 final examination application form

ABN 82 055 042 852
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
Training
FEX
Final Examination Form
1. FINAL EXAM REQUIREMENTS
Advanced Trainees applying for admission to the Final Examination must, by the application closing date, have submitted
documentation to validate that they have, by the date of the written section of the Final Examination (Regulation 14.5.1)
Completed PMET, Basic Training, and ATY1 (Reg. 14.5.1.1)
Completed 104 weeks of Clinical Training in Clinical Anaesthesia (Reg. 14.5.1.2)
Passed the Primary Examination or have been granted exemption (Reg. 14.5.1.3).
Please ensure that the college has received all required documentation and pay all outstanding training fees.
2. PERSONAL INFORMATION
ANZCA ID:
Family Name:
Date of Birth:
First name:
Middle Name:
Day
Month
Year
3. CONTACT INFORMATION
Postal Address:
Suburb/City:State:
Postcode:Country:
Mobile Phone:
Country
Local
Other Phone:
Country
Area
Local
Email Address:
4. EXAM DATE AND VENUE
Please select which examination sitting you will attend, and then your preferred venue for the Written and Medical
sections of the examination.
Please tick the preferred venue for the
1st Sitting
2nd Sitting
Written and Medical sections of the
examination.
Written & Medical
Written & Medical
20 & 21 March
21 & 22 August
Adelaide
Sydney
Oral (in Melbourne only)
22 & 23 May
Oral (in Sydney only)
23 & 24 October
Brisbane
New Zealand
Melbourne
Hong Kong
Perth
18 November 2014
PAGE 1 OF 3
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
ANZCA ID:
5. DECLARATION
I certify that:
a) I have no illness or disability that would preclude the safe practice of anaesthesia, intensive care medicine and pain
medicine, including dependence on or inappropriate use of alcohol or recreational and/or non-prescribed drugs, and/
or treatment with prescribed drugs likely to compromise the safe practice of anaesthesia, intensive care medicine or
pain medicine.
or
I have informed the College of any illness or disability that would preclude the safe practice of anaesthesia, intensive
care medicine and pain medicine, including dependence on or inappropriate use of alcohol or recreational and/or
non-prescribed drugs, and/or treatment with prescribed drugs likely to compromise the safe practice of anaesthesia,
intensive care medicine or pain medicine, and I am receiving appropriate medical care.
and
b) I undertake to notify the College if I develop an illness or disability that would preclude the safe practice of
anaesthesia, intensive care medicine and pain medicine, including dependence on or inappropriate use of alcohol
or recreational and/or non-prescribed drugs, and/or treatment with prescribed drugs likely to compromise the safe
practice of anaesthesia, intensive care medicine or pain medicine.
Signature:
Date:
Day
Month
Year
6. PAYMENT DETAILS
Australia
AUD $5353.00
Hong Kong, Malaysia and Singapore
AUD $5342.00
New Zealand
NZD $7772.00
Includes 15% GST
Cheque, Bank Draft or Money Order attached
(Payable to ANZCA and crossed “Not Negotiable”.)
Credit Card (please tick one)
Credit Card Number:
Name
on Card:
Expiry Date:
Cardholder’s
signature
Send the completed form together with the full amount of the fee to:
ANZCA
c/o Exams Unit
PO Box 6095
MELBOURNE
VIC 3004 AUSTRALIA
Fax: +61 3 9510 6786
Email: [email protected]
Please note: Only credit card payments will be accepted by fax or email. Please see Section 5 of
the notes.
18 November 2014
PAGE 2 OF 3
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
Final Examination Form (Notes)
FIRST SITTING
SECOND SITTING
20 & 21 March
(Closing date 13 January)
21 & 22 August
(Closing date 8 June)
Written & Medical Examination Dates
Oral Examination Dates and Venues
22 & 23 May (in Melbourne only)
Written & Medical Examination Dates
Oral Examination Dates and Venues
23 & 24 October (in Sydney only)
Applications and/or associated documentation will not be accepted after the closing date. Withdrawal fees
apply to candidates who withdraw from the exam as per Regulation 14.7.3.
Eligibility for Final Examination
To sit the Final Examination, you must have
submitted documentation to validate that you have,
by the date of the Written and Medical sections of the
Final Examination:
• Completed PMET, Basic Training and ATY1
• Completed 104 weeks of Clinical Training in
Anaesthesia
• Passed the Primary Examination or have been
granted exemption
• Paid all outstanding fees
• Submitted all Outstanding documentation
These eligibility requirements must be met by the date
of the Written and Medical sections of the
examination.
See Regulation 14 for further details on the Final
Examination.
Instructions for Completing the
Final Examination Form (FEX)
2. Personal Information
ANZCA Trainee ID: If you have not yet registered
or cannot locate your ID, contact the Training &
Assessments Unit on +61 3 9510 6299.
4. Exam Date and Venue
The Final Examination is held twice a year with each
sitting comprising a Written and Medical
section and an Oral section.
You must select (i) which sitting you will attend, and (ii)
where you will present for your Medical and
Written sections.
5. Declaration
The College requires that you sign this statement
stating that you do not have a dependency on
recreational and/or non-prescribed drugs.
6. Payment Details
Cheque: If you are paying by cheque it must be drawn
on an Australian bank in Australian dollars and made
payable to ANZCA.
Bank Draft or Money Order: These can be drawn by
any international commercial or postal bank, but must
be denominated in Australian dollars. They should be
made payable to ANZCA.
Cardholder’s Signature: If you are paying by credit
card, please ensure that you authorise your payment
with your signature.
First Name: If your first name is hyphenated or two
words, e.g., Wu Xiao Ping, Anne-Marie Jones, enter
this in the first name box.
3. Contact Information
Address, Phone and Fax Numbers: Please give your
country and area or city codes, in addition to your local
number. If you do not have an area or city code, e.g.,
Hong Kong or Singapore applicants, leave this space
blank.
Kindly advise the Final Exam Officer by email
([email protected]a.edu.au) if any of these
details change during the course of the exam.
18 November 2014
PAGE 3 OF 3