ABCN Exam Application Part I



MEDICAL TRAINING

POST GRADUATE MEDICAL TRAINING
(Including formal training in Neurophysiology)
 Hospital LocationDatesSpecialty
Year 1
Year 2
Year 3
Year 4
Year 5
CURRENT HOSPITAL/UNIVERSITY POSITIONS
IN WHICH STATE(S) DO YOU HAVE A CURRENT MEDICAL LICENSE?

DOCUMENTS


REFERENCES

I hereby declare that the facts in this application are true, and I agree to abide by the rules of the American Board of Clinical Neurophysiology, Inc. governing its examinations. I understand and agree that any misrepresentation of said facts or violation of any of said rules will result in automatic disqualification, or revocation of the Certificate, and I further agree to hold the American Board of Clinical Neurophysiology, its officers, members and agents and any of them harmless from any claim for damages as a result of any action, it, they or any of them may take in connection with this application, the examination, the result thereof and the failure to issue, or the revocation of a certificate.


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