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.

* 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

Country

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

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

* Sex / Gender

* Date of Birth

What is your date of birth?

DD /

MM /

YYYY

* Your government ID number, as it appears on the government-issued photo ID (such as a passport) that you will present at the exam site

* Are you an ESPNIC Member?

Yes, I am a current Member of ESPNIC

No, I am a nonmember

* 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]")