Certification Examination

2015 CBNC CERTIFICATION EXAMINATION
APPLICATION FORM
The application forms constitute one part of the required documentation. Be sure to include all
documents listed in the Bulletin and on the Checklist page. Please TYPE or PRINT legibly.
Office Use
Recd: ____________________
Amount: _________________
Type: _______ Rev: _________
1. Print Official Name as listed on the Government Issued Photo ID you will used to identify yourself at the testing site:
______________________________________________________________________________________________________
First Middle Last Degrees
2. Print Name as you wish it to appear on your Certificate (may be different from Official Name)
______________________________________________________________________________________________________
First Middle Last Degrees
3. Preferred Address (select only one) Home Office
______________________________________________________________________________________________________
Facility Name (if you selected Office above)
Department
______________________________________________________________________________________________________
Street Apt/Suite #
______________________________________________________________________________________________________
City State Postal Code Country
4. Preferred Method of Contact (select one): Office Phone Home Phone Mobile Phone Email
Email ________________________________Tel (O) __________________ Tel (H) ________________ Tel (M)___________
Please provide email address in order to receive status updates.
5. Date of Birth (mm/dd/yy): ___/___/___ 6. Gender: M F 7. Last 4 Digits of SS Number: ______ 8. 6-Digit ABIM ID:____________
9. Preceptor: _______________________________________________________________________________________________________
Name Telephone Email Address
10. I hold a current, unconditional, unrestricted medical license in the following state(s)/country(ies):______________________________
11. Testamur Candidates: I am applying as a Testamur Candidate. I currently have a training license or am covered under the
institutional training license. I will provide a copy of my license and a letter from my program director verifying my good standing within the
program. I understand that in order to receive a CBNC Certificate and to be listed as a Diplomate of the Board, I must provide evidence of
Cardiology, Nuclear Medicine or Radiology board certification (U.S. Applicants) or a copy of my specialty area diploma (Non U.S. Applicants)
within 6 years of passing the CBNC certification exam. I understand I must also provide evidence of a full, unconditional, unrestricted
medical license at the time I provide my CVD, NM or R board certification/diploma. I understand that my certification period will be 10
years from the date of the CBNC exam I passed.
12. My medical training (most recent to earliest):
A) Institution:_____________________________ Specialty: _______________ Begun (mm/yy): ___/___ Completed (mm/yy)___/___
B) Institution:_____________________________ Specialty: _______________ Begun (mm/yy): ___/___ Completed (mm/yy)___/___
C) Institution:_____________________________ Specialty: _______________ Begun (mm/yy): ___/___ Completed (mm/yy)___/___
13. U.S. Candidates only: I am Board Certified in the following ABMS or AOA Boards (CD, NM, R; Testamur Candidates only; include IM):
A. ____ year certified: _______B. _______________ year certified: _____C. _______________ year certified: ________
I do not reside or practice in the United States and no Board Certification exists in my county for my specialty. I have enclosed a copy of
my CD, NM or R diploma with English translation (not applicable for Testamur Applicants).
14. My primary professional setting is (check all that apply):
Private Practice, Group Private Practice, Solo Hospital Medical School Fellowship/Residency
Other_____________________
2015 CBNC Certification ‐ Page 22