Name *

First Name

Last Name

Affiliation *

Tick the appropriate box and submit written evidence of your affiliation

RANZCR

ANZAN

NSA

Medical Registration *

Evidence of Medical registration

I have attached evidence of my medical registration

Training Service Requirements *

You must submit evidence from your Supervisor(s) that the Training Service(s) you were attached to meets the standards set out in Section (3) of the CCINR Guidelines.

The training team was appropriately credentialed

Full Neuroscience support is available on site

The service performs a minimum of 100 INR procedures a year with a least 50 aneurysms (see Section 3.2)

The training position was integral to the Training service (3.3)

Evidence of regular audit, M&M supplied

Experiential requirements *

You must supply information confirmation the duration and composition of formal training in INR

I have supplied evidence of formal INR training of not less than 2 years full time equivalent

I have supplied evidence of regular formal teaching as set out in Section 4.2

I have completed the requirements for procedural experience (Section 4.3), documented in the CCINR logbook proforma

Supervisor Confirmation of Training *

You must submit written confirmation of your training from an appropriately credentialed supervising INR (see Section 5.2) confirming each subsection of Section 5.3. In addition, each of your Supervisors must complete a Supervisors Declaration form.

I have written reports confirming my training from at least two Supervisors

I have signed Declarations from each of my Supervisors

Cover letter *

You must supply a cover letter with your application, outlining your training period. It is particularly important to indicate periods of overseas training, and any breaks in training you may have experienced.

I have supplied a cover letter with my application

Curriculum Vitae *

You must submit a copy of your curriculum vitae with your application

I have submitted a copy of my curriculum vitae

Applicant Declaration *

You must download, read, sign and return the Applicant Declaration

I have completed the Applicant Declaration

Application Fee *

Applicants must pay an application fee

I agree to submit payment when invoiced for my CCINR Application ($321 initial, $272 recert, *at Nov21, subject to increase)