Save & Return

Save your progress and complete this form later. (optional)

Petition of Eligibility for CLTM

This form must be submitted prior to your exam application.

Your Information

Date *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address *

Phone Number *

Hospital/Institution: *

Laboratory/Department/Program Name:

Street Address

City

State/Province/Region

Zip/Postal Code

Instructor/Manager: *

Instructor/Manager Email Address *

Instructor/Manager Phone Number *

Primary reason you are petitioning your eligibility for the CLTM exam: *

If you selected "Other", please provide the primary reason your are petitioning *

Briefly explain the reason you are unable to fulfill the requirements: *

Years of experience in neurodiagnostics: *

Please provide a brief description of your experience Long Term Monitoring: *

Long Term Monitoring procedures you personally perform (Check all that apply):

	Yes
Epilepsy Monitoring (adult)	Yes
Epilepsy Monitoring (pediatric)	Yes
Intraoperative Electrocorticography	Yes
Extraoperative Cortical Stimulation/Mapping	Yes
PET, Functional MRI, other specialized monitoring	Yes
Wada Testing	Yes
SPECT Monitoring	Yes
ICU Monitoring	Yes
Ambulatory Monitoring	Yes

Upload any LTM cases you are able to provide: *

Upload letter of recommendation if needed:

A $15.00 fee is required for submission and review of this form *

Petition Review Fee ($15.00)

*continue to the next page for submission and fee.