International CardioOncology Society, North America

THE INTERNATIONAL CARDIO-ONCOLOGY SOCIETY (ICOS)

Cardio-Oncology

BOARD CERTIFICATION EXAMINATION

FIRST TIME APPLICANTS

Name :

Gender:
MaleFemale

Date Of Birth:

Intended Exam Date:
I wish to take examination (March 2020).I wish to take examination (October 3, 2020).

EXAM PREREQUISITES

English translations of all documents in other languages must be provided by the applicant.

Medical Education:

Name of Medical school:

Date of Graduation:

Medical Licensure:

Upload a copy of your medical license here (Please upload files in PDF, Doc, JPG or PNG format.)

Cardio-Oncology Fellowships:

Start Date :

End Date :

Practice Qualifications:

Fellowship/Advanced Training : (If Completed)

Description of Cardio-Oncology activities:

REFERENCES

Please provide at least 2 reference letters (ONE FROM A CARDIOLOGIST AND ONE FROM AN ONCOLOGIST) attesting to your cardio-oncology expertise (if you have a letter from a Program Director for fellowship training, that will serve as one of those references) (Please upload files in PDF, Doc, JPG or PNG format.)

APPLICATION STATEMENT

I hereby apply to The International Cardio-Oncology Society(ICOS) for the opportunity to take a certifying examination, and if I successfully complete this test, issuance to me of a certificate of qualification as a specialist in Cardio-Oncology on the basis of successfully meeting all of the requirements relative thereto, all in accordance with and subject to the bylaws, rules, regulations, and registration fees of ICOS in force at this time.

I understand and agree that as an applicant:

I have the responsibility for supplying to the ICOS the necessary information adequate for a proper evaluation of my credentials.
I have the responsibility to update any information required in connection with my application, including providing ICOS complete information relating to any restrictions on, or the suspension or revocation of, my medical license(s) within 60 days of any such restriction, suspension, or revocation.
I may be disqualified from sitting for an examination or from issuance of a certificate in the event that any of the statements herein made on this application, or hereafter supplied by me to the ICOS, are false or if I have failed to provide material information or in the event that any of the rules governing such examination are violated by me.
I request and authorize the evaluation and validation of my credentials in accordance with, and subject to, the rules and regulations of the ICOS.
ICOS may release the results of my examination(s) to the director of my training program.
ICOS may provide information to appropriate parties concerning my status as Board certified or not certified, dates and bases for action(s) related to my certification, and/or other appropriate information; all disclosures will be in compliance with the law.
All decisions as to my credentials and qualification for admission to the examination and for certification rest solely and exclusively in the ICOS, that its decision is final, and my exclusive appeal from any adverse decision is pursuant to the ICOS's rules and procedures.
I hereby release, discharge, covenant not to sue, and hold harmless the ICOS, its trustees, officers, members, examiners, representatives, agents, and any person who supplies information regarding my credentials from any actions, suits, claims, demands, or damages arising out of, or in connection with any action taken by any of them regarding this application, the gathering, collecting, and use of information about my practice or education, the results given with respect to any examination, the failure of the ICOS to certify me, or the revocation of any certificate.

I Agree :

Testing Responsibilities:

I understand and agree that in order to maintain a fair and secure testing process that:

The examination and all test questions are the exclusive property of the ICOS and are protected by copyright law. Because of the confidential and proprietary nature of these copyrighted materials, I agree not to retain, copy, disclose, discuss, share, reveal, distribute, or use for exam preparation any part of these examination materials, including memorized, reconstructed and recalled items.
The following actions may be sufficient cause for ICOS, in its sole discretion, to terminate my participation in an examination, to invalidate the results of my examination, to withhold or revoke my scores or certificate, to bar me from future examination, or to take other appropriate action.

Referring to books, notes, or other devices at any time after the start of the examination, including breaks. This prohibited material includes written information or information transferred by electronic, acoustical, or other means.
Any transfer of information or signals between candidates during the administration of the examination, including breaks.
Any appearance of looking at the computer screen of another candidate during the examination.
Allowing another candidate to view one’s answers or otherwise assisting another candidate in the examination.
Recording, replicating, recalling, or discussing examination questions, and taking any information on examination questions, such as notes or diagrams outside the examination room.

The unauthorized possession, reproduction, disclosure, discussion, or distribution of any examination materials, including, but not limited to, examination questions, answers, reconstructed and recalled items at any time before, during, or after the examination.
The offering of any benefit to any agent of ICOS in return for any right, privilege, or benefit which is not usually granted by the ICOS to other similarly situated candidates or persons.
ICOS may require me to retake one or more portions of an examination if presented with sufficient evidence that the security of the examination has been compromised, notwithstanding the absence of any evidence of my personal involvement in such compromise.

I Agree :

I understand and agree that :

If I meet all of the qualifications for certification, my certificate will be valid for 3 years contingent upon my timely satisfaction of all requirements for continuing education by my primary professional society.

Signature :

Date

If successful, I would like to have my name inscribed on my certificate as follows:

TO PAY EXAMINATION FEE CLICK SUBMIT

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Board test