1. 2. 3. Primary Specialty Certification Current Certificate Certification Number ╬ Date on Date Certificate Certificate or (MM/DD/YY) Recertification Expires (MM/DD/YY) Subspecialty Date of Certification Certification under ABMS (MM/DD/YY) Indicate if you are certified by a member board of the American Board of Medical ╬ Specialties, or possess equivalent certification by the Royal College of Physicians and Surgeons of Canada. Applicants who have qualified for examination by these organizations but have not been certified, may sit for a subspecialty certification examination approved by the UCNS but may not receive notice of the results of that examination until the above criterion has been satisfied. A letter from the specialty Board indicating that the applicant is approved for primary specialty certification must accompany the application. Licensure Must provide copies of all current state and medical licenses. Submit a copy of each license as Attachment A. State: Exp Date: Number: State: Exp Date: Number: Province (if applicable): Exp Date: Number: ╬ ╬ Canada only (Province) YES NO Are you currently in possession of a restricted, suspended, or revoked medical license in any state? If yes, please attach a letter of explanation. YES NO Do you currently have any Board action pending against you before any State Licensing Board? If yes, please enclose a letter of explanation. 7. Fellowship Training in Neurocritical Care: one of two Applicants must have completed eligibility pathways (Pathway A—Fellowship or Pathway B—Practice Track) A. PATHWAY A FELLOWSHIP –
1. 2. 3. Primary Specialty Certification Current Certification ╬ Certificate Number Date on Certificate (MM/DD/YY) Date Certificate or Recertification Expires (MM/DD/YY) Subspecialty Certification under ABMS Date of Certification (MM/DD/YY) ╬ Indicate if you are certified by a member board of the American Board of Medical Specialties, or possess equivalent certification by the Royal College of Physicians and Surgeons of Canada. Applicants who have qualified for examination by these organizations but have not been certified, may sit for a subspecialty certification examination approved by the UCNS but may not receive notice of the results of that examination until the above criterion has been satisfied. A letter from the specialty Board indicating that the applicant is approved for primary specialty certification must accompany the application. Licensure Must provide copies of all current state and medical licenses. Submit a copy of each license as Attachment A. State: Exp Date: Number: State: Exp Date: Number: ╬ Province (if applicable): Exp Date: Number: ╬ Canada only (Province) YES NO Are you currently in possession of a restricted, suspended, or revoked medical license in any state? If yes, please attach a letter of explanation. YES NO Do you currently have any Board action pending against you before any State Licensing Board? If yes, please enclose a letter of explanation. 7. Fellowship Training in Neurocritical Care: Applicants must have completed one of two eligibility pathways (Pathway A—Fellowship or Pathway B—Practice Track) A. PATHWAY A – FELLOWSHIP