Clinical Cardiology Course Application Form

Identify desired date and time for CCC-Session 1 *

Identify desired date and time for CCC-Session 2 *

Identify desired date and time for CCC-Session 3 *

Identify desired date and time for CCC-Session 4 *

Will you be taking one of our Cardiology Exams at the conclusion of this Course? *

Yes No Undecided

State Issued Valid ID Required - Scan and submit with application to blucido@accn.net *

Reason for Taking the Clinical Cardiology Course: *

If you Selected Other Status, Please Identify *

Provide your Professional NP or PA License Number *

State Where License Issued *

Identify Certifications Currently Held *

Home Mailing Address Including Apt. or Unit number *

Zip Code or Country Code *

Country of Residence *

Home Phone - Cell Preferred (include area code) *

Work Phone (include area code) *

Private Email Address *

Work Email Address *

Name of Employer: example: St. Joseph's Hospital of Brookville *

Area of Cardiology Employed in. *

Supervisor Name and phone number *

Length of Time Working in Cardiology Areas *

How did you Learn Cardiology? *

College Course Seminars and Workshops My Hospital Supplied the Needed Training I learned on the job and am self taught

Identify any personal special needs that we need to consider during the Course and/or Exam. *

How did you learn about the ABCM's Courses and Certification Exams? *

TERMS OF USE: Must sign into the Course Sessions on a PC or MAC computer from home, no hospital locations unless prior authorization is sought and approved in writing by ABCM administration. We also do not allow anyone to log into the Course Sessions on a cell phone, and we do not allow anyone to record the Course Sessions from a cell phone or any other device (recording or downloading of the Course Sessions is not allowed and is considered an infringement of ABCM's copyright and will be strictly enforced). Think of the online Course Sessions as you attending a live class where the instructor does not allow you to record the class. You may attend each Course Session a second time for a fee of $40 per Session. You need to be on time for each Session or you will not be admitted as it disrupts the program when we stop to let you into the Session. You may however wait till the topic you were late for is over and then join the next topic in your scheduled Session. You will need to email Bobbi Lucido blucido@accn.net, our course registrar to get another login code and date to catch the Session you missed. There will be a late fee of $15 imposed for rescheduling which must be paid before being given another code *

Clinical Cardiology Course/Exam Application & Registration