EPIC Diploma Program - Initial Certification Application

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Please complete this online form to apply for the EPIC Diploma Program. Questions about the application process may be directed to epic@espnic-online.org or +41 22 560 7401. One of our Credentialing Department team members will respond to your message within three business days.

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* Applicant's Contact Information

Surname / Family Name / Last Name *

Given Name / First Name *

Street Address, line 1 (mailing address of your current residence) *

Street Address, line 2

City / Town

State / Province / Region

Postal Code

Email Address, to which you consent that we will send all EPIC Diploma-related communications, including your eligibility determination, follow-up on incomplete applications, exam administration information, exam results, information about continuing professional development (CPD) opportunities, and recertification notices *

Cellular Phone Number (include "+[countrycode]") *

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* Country in which you are currently working and residing

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* Sex / Gender

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* Date of Birth

What is your date of birth?

Date

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* Your government ID number, as it appears on the government-issued photo ID that you will present at the exam site; if you will be testing outside of your country of citizenship, you MUST use your passport ID # for this, since you will need your passport to check into the test centre.

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* Employer Information

Supervisor's Full Name *

Primary Employer (name of the hospital / university / organization / institution where you work) *

Employer's Street Address, line 1 *

Employer's Street Address, line 2

City / Town

State / Province / Region

Postal Code

Country *

Supervisor's Email Address

Supervisor's Phone Number (include "+[countrycode]") *