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ABCN Exam Application

Please select your testing window

First Name *

Middle Name

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Primary Email Address *

Secondary Email Address

Date of Birth (MM/DD/YYYY) *

MEDICAL TRAINING

Medical School

Years Attended

Location

Degree Awarded

POST GRADUATE MEDICAL TRAINING

(Including formal training in Neurophysiology)

	Hospital Name/Location	Dates	Specialty
Year 1	Hospital Name/Location	Dates	Specialty
Year 2	Hospital Name/Location	Dates	Specialty
Year 3	Hospital Name/Location	Dates	Specialty
Year 4	Hospital Name/Location	Dates	Specialty
Year 5	Hospital Name/Location	Dates	Specialty

OTHER

Current hospital/university positions:

+-

American Specialty Board Certification
(Specialty & date of certification. If not certified, indicate board eligibility)

Do you have any of the following American Subspecialty Certifications?

In which states(s) do you have a current medical license?

+-

DOCUMENTS

Please Upload Your Medical License *

REFERENCES

Clinical Neurophysiology Program Director

Director, Residency Training Program

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.

Electronic Signature of Applicant *

Date (MM/DD/YYYY) *

EXAMINATIONS

ABCN requires a one-time application fee. If you have applied for a previous ABCN exam and have already paid the application fee, please bypass this fee and select your exam(s).

One-Time Application Fee

One-time Application Fee

Select exams: *

General Clinical Neurophysiology (Available to all, but required if no subspecialty certification through ABPN) ($600.00)

Epilepsy Monitoring ($600.00)

Intraoperative Monitoring ($600.00)

Critical Care EEG ($600.00)

Pediatric EEG ($600.00)

Current Total:

$0.00

*You will be prompted for payment on the next page