Neuro IC Exam Registration - The American Board of Radiology

11-13DO NOT WRITE IN THIS SPACEPrevious certification verified:Admissible? Y NDate received:Date reference requested:Date admissible:Application number:NeuroradiologyRegistration for Subspecialty CertificationMake two copies of this application with original signatures. Use extra paper for additional data if necessary.TYPE OR PRINT (IN INK) ALL INFORMATION________________________________________________________________ Male FemaleLast name First name Middle namePlease indicate the pathway under which you are applying: Standard Pathway Alternate PathwayAddress to which you want Board correspondence sent:________________________________________________________________________________________________________Street Address___________________________________________________________________________________City State ZipLast four digits of your Social Security Number (U.S. or Canadian) ______________________________Telephone Numbers: Office: ____________________________ Fax: ___________________________Home: ____________________________ Fax: ___________________________Email Address: _______________________________________________________________________When did you receive your diagnostic radiology certification? __________________________________MonthYearMy name at the time of this certification was: the same differentIf different, what was your name? ________________________________________________________Other specialty board certification: _______________________________________________________BoardDate1

Fellowship Program (Standard Pathway Only)11-13BeganCompletedInstitution City and State MM DD YY MM DD YYPlease list contact information for the program director of your neuroradiology fellowship:Full Name:Address:Street Address or PO Box City State Zip CodeClinical Practice (Standard Pathway Only)Institution(Please list current institution first.)City and State% TimeNeuro RadFromToa)b)c)d)Faculty Member Experience (Alternate Pathway Only)Institution City and State % TimeNeuro RadFromToPlease list contact information for the chair of your department:Full Name:Address:Street Address or PO Box City State Zip Code2

any reproduction of copyrighted material is a federal offense, and may also subject me to discipline by the Board inaccordance with its policies and procedures. In the event the Board conducts a hearing into an examination irregularityat which I am either the subject of the investigation or a witness to the actions of one or more other examinees, I willcooperate fully with the Board, including appearing at any hearing and providing testimony.11-13To help analyze the effectiveness of the training program and/or department in which I prepared for my examination(s), Ihereby authorize the Board to release, in confidence, to the director(s) of the program in which I am enrolled or wasformerly enrolled, and to the chair of the department of which the program is a part, the results of my performance onthe examinations conducted by the Board.Throughout my candidacy for initial primary (general) or subspecialty certification, I consent to have my name anddemographic data published, along with my board eligibility status. If I become certified, I consent to have my name anddemographic data (including type and date of all ABR certifications and MOC status) included in any list or directory inwhich the names of diplomates of the specialty boards are published. I agree that the Board is not liable for informationprovided to the medical community or to the public regarding my certification status, and I further agree that I willpromptly notify the Board of any error or omissions in such information.If I become certified, I understand and agree that the continued validity of my certificate will be contingent upon mymeeting the requirements of the Maintenance of Certification Program (ABR-MOC) administered by the Board, asamended from time to time. I understand that the ABR-MOC program is designed to monitor my professional standing,lifelong learning and self-assessment, cognitive expertise, and practice quality improvement, each an MOC componentfor which I am responsible. I agree to participate in ABR-MOC in accordance with and subject to stated policies andprocedures, as amended from time to time, including timely payment of fees. The Board does not undertake anyresponsibility to provide individual diplomates with notice of changes to MOC policies. I further understand it is myresponsibility to stay informed regarding all phases of the MOC program and my progress therein, through my personaldata base and the ABR website. I will keep truthful and accurate records of my participation in the MOC program, and Iwill promptly advise the Board of any change of my current contact information.I understand that it may be necessary to revise and update this Agreement at a later date, and that as a condition ofcontinued certification and/or participation in MOC, that I may be required to execute and return to the Board a revisedAgreement, which shall replace and supersede the terms of this Agreement. The portions of this Agreement relating toexamination security are subject to modification by the Board in the most current version of its Exam Security Policy postedon its website and/or in specific agreements that may be required in order to register for or to take an examination.I waive and release and shall indemnify and hold harmless the Board and its trustees, directors, members, officers,committee members, employees, and agents from, against and with respect to any and all claims, losses, costs,expenses, damages, and judgments (including reasonable attorneys’ fees) alleged to have arisen from, out of, withrespect to or in connection with any action which they, or any of them, take or fail to take as a result of or in connectionwith this Agreement, any examination conducted by the Board which I apply to take or take, the grade or grades givenme on the examination and, if applicable, the failure of the Board to issue me a certificate or qualification or the Board'srevocation, suspension or probation of any certificate or qualification previously issued to me and/or the Board’snotification of any interested parties of its actions.By signing this application, I agree to the terms and conditions listed above.Signature: ______________________________Date: ___________________________4

11-13PLEASE CHECK OFF ITEMS AS YOU COMPLETE THEM.THIS PAGE IS PART OF YOUR APPLICATION.IT MUST BE SENT TO THE ABR.Submit two copies of the application with original signatures.If you are applying via the Standard Pathway, submit one original letter from your programdirector, documenting your fellowship training.If you are applying via the Standard Pathway, submit one original letter from your chief ofservice or department chair, documenting your practice experience.If you are applying via the Alternate Pathway, submit one original letter from your departmentchair documenting your faculty experience and percentage of time spent in neuroradiology.Submit a copy of your valid state medical license. (You are only required to send a copy ofone medical license, even if you are licensed in more than one state.)Sign the following statement:All of my current state medical licenses are valid and unrestricted.____________________________________________Signature______________________DateBefore submitting a subspecialty registration, you must have paid any outstanding ABR fees infull. Be sure your application is complete. Incomplete applications will NOT be accepted. Thepostmark affixed to the last item received to complete the application must be on or before thedeadline date.Pay for your exam. All All payments must be in U.S. currency. Payment may be made bypersonal check, money order, VISA, MasterCard, or American Express, payable to UTheAmerican Board of RadiologyU. If your payment is declined Ufor any reason U, there will be a$100 processing fee. If paying by credit card, please attach a completed Credit Card Form(following page). Please note that the ABR cannot accept credit card forms by email.Mail at the appropriate time. Applications will be accepted beginning February 1 of the examyear. The filing deadline for the examination in any given year is April 30 of the exam year.There is an additional fee for applications postmarked between May 1 and May 31 of the examyear. No applications will be accepted after May 31 for examination in that year. For feeamounts, please visit www.theabr.org/ic-neuro-dates.Send completed applications, payment and letters to:THE AMERICAN BOARD OF RADIOLOGY5441 E. WILLIAMS CIRCLETUCSON, ARIZONA 85711-74125

11-13CREDIT CARD FORMPlease note that the ABR cannot accept credit card forms by email.Candidate name: __________________________________________________________________Exact name that appears on credit card: ________________________________________________The following information must be as it applies to billing of the credit card.Billing address: ___________________________________________________________________City: ________________________________ State: _________________ Zip Code: __________Phone: ____________ - _____________ - _________________________Credit Card# (no spaces):VISA ☐ MasterCard ☐ American Express ☐Expiration date: _____________________ Amount authorized: $____________________1BSignature of cardholder: ______________________________________________If your payment is declined for any reason, there will be a $100 processing fee.For office use onlyABR ID #: _____________________Fee Code: ___________________Send to:THE AMERICAN BOARD OF RADIOLOGY5441 E. WILLIAMS CIRCLETUCSON, ARIZONA 85711-7412FAX: (520) 790-32006