Fellowship Form Testing

Application For Fellowship In The Canadian Academy Of Clinical Biochemistry

I am applying under the following: (See Requirements for Fellowship; check only one category):(Required)

Requirement 1

Requirement 2

Requirement 3

Total payment of $450 = $300 Application Fee + $150 Certificate Printing/mailing Fee * I understand that I need to take and pass the CACB Written and Oral Examinations in order to be qualified for Fellowship.

Subtotal

$ 0.00 CAD

(Tax calculated below - if applicable)

Name(Required)

First Last Initial

Certification(Required)

Yes

Certification Date(Required)

Certification By(Required)

CACB

OCQ

Other

Other: Please Enter Name & Corresponding Address(Required)

CACB Oral Examination Taken(Required)

Yes

CACB Oral Examination Date(Required)

Applicants having successfully completed the CACB written and oral examinations should proceed to the SIGNATURES section.

All other applicants must complete all remaining sections.

NOTE: Selecting "NO" on the question "CACB Oral Examination Taken" (above) reveals the remaining sections.

UNIVERSITY DEGREES: Please attach photocopies of diplomas and certification documentation.(Required)

Year

Discipline

University

UNIVERSITY DEGREES DOCUMENTATION(Required)

Drop files here or

Max. file size: 120 MB.

ACADEMIC APPOINTMENTS:(Required)

Position

University

Effective date

Number of years of professional experience in clinical biochemistry(Required)

Full member of the Canadian Society of Clinical Chemists since(Required)

POSITIONS HELD SINCE COMPLETION OF ACADEMIC TRAINING:(Required)

Position

Institution

Inclusive dates

LIST OF TWO PROFESSIONAL REFERENCES:

The Credentials Committee of the Academy requires two (2) letters of reference to support the application.

One of these letters must be from your Post-Doctoral Clinical Chemistry/Biochemistry Training Program

Director. Please arrange to have these emailed directly to CACB Head Office.

NOTE: Reference letters are not required for applicants who apply under requirement #1 (who have successfully

completed the CACB Oral Examination) and # 2.

Reference letters are required to contain comments on the following categories:

Ability to function as a clinical biochemist
Aptitude to work under challenging and stressful conditions
Description of communication skills (written and oral)
Problem solving skills
Ability for methodology development
Other skills of interest in the field of Clinical Biochemistry

Please note that all categories must be identified. If the referee is unable to comment on a particular item, if should be noted as "I cannot comment on this item".

POSITIONS HELD SINCE COMPLETION OF ACADEMIC TRAINING:(Required)

Position

Full address

Telephone number

SIGNATURES:

I attest that the above statements are true, and I hereby apply for fellowship in the Canadian Academy of Clinical Biochemistry.

Applicant Signature(Required)

Date(Required)

Full mailing address(Required)

Street Address Address Line 2 City Province / State Postal Code / ZIP Country

Telephone(Required)

Email(Required)

Have you attached the following documents to your email?

Copy of your CV (if applying under category 2-3)
All supporting documentation, including copies of diplomas, certifications, and degrees relating to Clinical Chemistry/Biochemistry

GST

(Alberta, British Columbia, Manitoba, Northwest Territories, Nunavut, Saskatchewan or Yukon)

$ 0.00 CAD

HST

(Ontario)

$ 0.00 CAD

HST

(Nova Scotia)

$ 0.00 CAD

HST

(New Brunswick, Newfoundland and Labrador or Prince Edward Island)

$ 0.00 CAD

GST

(Quebec)

$ 0.00 CAD

PST

(Quebec)

$ 0.00 CAD

Tax

(Non-resident)

$ 0.00 CAD

Total

Credit Card(Required)

Card Details

Cardholder Name

Fellowship Form Testing

Fellowship Application Form - Requirements 1-3

Application For Fellowship In The Canadian Academy Of Clinical Biochemistry

LIST OF TWO PROFESSIONAL REFERENCES:

SIGNATURES:

Have you attached the following documents to your email?