Primary Examination Form 2015 PEX

ABN 82 055 042 852
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
Training
PEX
Primary Examination Form 2015
NOTE: Please ensure that you meet the eligibility criteria described in the Notes, and verify that the College has received
all required documentation including all outstanding fees.
1. PERSONAL INFORMATION
ANZCA ID:
Family Name:
Date of Birth:
First Name:
Middle Name:
Day
Month
Year
2. CONTACT INFORMATION
Postal Address:
Suburb/City:State:
Postcode:Country:
Mobile Phone:
Country
Local
Other Phone:
Country
Area
Local
Email Address:
3. EXAM DATE AND VENUE
Please select which examination sitting you will attend, and then your preferred venue for the Written section of the
examination. The viva examination will be held in Melbourne only.
1st Sitting
2nd Sitting
Written: 23 February 2015
Written: 10 August 2015
Oral:21-23 Sept (Melbourne)
Oral:13-15 April
(Melbourne)
Written venue: Oral venue: Melbourne
For the Written sections you must select a venue from one of the following locations:
Adelaide, Brisbane, Cairns, Canberra, Darwin, Hobart, Launceston, Melbourne, Newcastle,
Perth, Sydney, Townsville
Auckland, Christchurch, Dunedin, Hamilton, Wellington
Other ANZCA Regions: Hong Kong, Kuala Lumpur, Singapore
Australia: New Zealand: 4. DECLARATION
I certify that I am free from dependency on recreational and/or non-prescribed drugs, and have no illnesses that would
preclude the safe practice of anaesthesia. I undertake to inform the College if I develop dependence on recreational
and/or non-prescribed drugs, or if I develop an illness that would preclude the safe practice of anaesthesia.
I acknowledge that if I develop any dependence on recreational or non-prescribed drugs, or any condition that precludes
the safe practice of anaesthesia, this may result in the suspension or termination of my training at any time, and prevent
my admission to Fellowship of ANZCA.
Signature:
18 November 2014
Date:
Day
Month
Year
PAGE 1 OF 4
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
ANZCA ID:
5. ELIGIBILITY CONFIRMATION
Applicants must have fulfilled all eligibility requirements at the date of application, or will do so by the date of the written
section of the relevant examination. In the latter circumstance an applicant must provide a written statement from
his or her supervisor of training certifying that he or she will have completed all entrance requirements by that date.
(Regulations 37.7.3.1.2, 37.7.3.1.3, and 37.7.3.3.2)
Please list your current training site and the name of your SOT. If you are currently in interrupted training, list
the details from your most recent position.
Training site:
Please mark
SOT name:
X
and answer A, B or C to indicate eligibility requirements
A. I have commenced basic training and I am in compliance with the requirement to be in approved vocational
training.
B. I will be in basic training extended (BT-E) at the time of written exam and I am in compliance with the
requirement to be in approved vocational training.
C. I will be in interrupted training at the time of the written exam.
If you have not yet commenced basic training at the time of application, your eligibility needs to be confirmed
by your SOT.
1. Documentation confirming compliance with all eligibility requirements will be submitted to the College via
TPS at least two weeks prior to the date of the written section. If the documentation cannot be submitted by
that date, I will advise the College of this by two weeks prior to the date of the written section, and the required
documentation will be provided at the earliest opportunity and no later than seven calendar days prior to the
date of the written section.
2. I understand that if formal confirmation of eligibility to sit has not been received by the College from the SOT
two weeks prior to the date of the written section, and full documentation not received by seven calendar days
prior to the written section, the trainee will be deemed to have withdrawn from the examination and relevant
penalties apply.
Supervisor confirmation
Comments, if any:
Supervisor’s
Name:
18 November 2014
Signature:
Day
Month
Year
PAGE 2 OF 4
AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
ANZCA ID:
6. PAYMENT DETAILS
The examination fee must be paid at the time of application to sit the primary exam (regulation 37.5.2.7.1).
Australia
AUD $4813.00
New Zealand
NZD $6988.00
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:
Expiry Date:
Name on Card:
Cardholder’s signature:
Send the completed form together with the full amount of the fee to:
ANZCA
c/o Exams Unit
PO Box 6095
ST KILDA ROAD CENTRAL
VIC 8008 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
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AUSTRALIAN AND NEW ZEALAND
COLLEGE OF ANAESTHETISTS
Primary Examination Form 2015 (Notes)
FIRST SITTING
SECOND SITTING
23 February 2015
(Closing date 19 December 2014)
10 August 2015
(Closing date 13 June 2015)
Written Examination Date
Oral Examination Dates and Venues
13-15 April 2015 (Melbourne)
Written Examination Date
Oral Examination Dates and Venues
21-23 September 2015 (Melbourne)
Applications and/or associated documentation will not be accepted after the closing date. Withdrawal
penalties apply to candidates who withdraw from the exam as per Regulation 37.7.3.4.
For the Written section you must select a venue from one of the following locations.
Australia: New Zealand: Other ANZCA Regions: Adelaide, Brisbane, Cairns, Canberra, Darwin, Hobart, Launceston, Melbourne,
Newcastle, Perth, Sydney, Townsville
Auckland, Christchurch, Dunedin, Hamilton, Wellington
Hong Kong, Kuala Lumpur, Singapore
Eligibility for Primary Examination
These eligibility requirements must be met and
submitted to the College via TPS at least two weeks
prior to date of the Written section of the examination.
See Regulation 37 for further details on the Primary
Examination.
Instructions for Completing the
Primary Examination Form (PEX)
1. Personal Information
ANZCA Trainee ID: Your ANZCA Trainee ID is the
five digit number you receive once you register. It
will be on your Registration documentation and most
personalised material received by you from ANZCA. If
you have not yet registered or cannot locate your ID,
contact the Records management Unit on +61 3 9510
6299.
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.
2. 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 Primary Exam Officer by email
([email protected]) if any of these
details change during the course of the exam.
18 November 2014
3. Exam Date and Venue
The Primary Examination is held twice a year with each
sitting comprising a Written and an Oral section.
You must select (i) which sitting you will attend, and
(ii) where you will present for your Written and Oral
sections.
4. Declaration
The College requires that you sign this statement
stating that you do not have a dependency on
recreational and/or non-prescribed drugs.
5. Eligibility Confirmation
The college requires that your SOT sign the form as
an acknowledgement by the SOT of trainee eligibility,
pending documentation is to be submitted, and that the
trainee will have commenced BT by the written date of
the exam.
6. Payment Details
Cheque: If you are paying by Cheque it must be
payable to ANZCA and drawn on:
• An Australian bank in Australian dollars (for
Australian trainees)
• A New Zealand bank in New Zealand dollars (for
New Zealand trainees)
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.
Credit card: The College can only accept payments
made by Visa and Mastercard. Please ensure that you
authorise your payment with your signature.
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