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CBNE Certification Examination Application Form

2014 CBNE Certification Examination Application Form

Candidates are required to submit an NRC preceptor form. You can download this form here

Applications may be submitted online or to:
Certification Board of Nuclear Endocrinology
245 Riverside Ave, Suite 200
Jacksonville, FL 32202

List your official name as on your government issued photo ID you will use to identify yourself at the testing site:

List your name as you wish it to appear on your certificate (may be different from official name):

CONTACT INFORMATION

My medical training (most recent to earliest):

Classroom and Laboratory Training

A minimum of 80 hours review of radiation physics and instrumentation, radiation protection, mathematics pertaining to the use and measurement of radioactivity, chemistry of byproduct material for medical use, radiation biology, the effects of ionizing radiation and radiopharmaceuticals. There should be a thorough review of regulations dealing with radiation safety for the use of radiopharmaceuticals and ionizing radiation. This coursework must have been completed within the past 7 years.

If you have 80 hours of classroom and laboratory training other than the AACE Nuclear Endocrinology Training Program, use the Contact Form for further instructions.

PLEASE READ AND VERIFY THE FOLLOWING STATEMENTS

  • I, the undersigned, hereby apply for certification through the Certification Board of Nuclear Endocrinology (CBNE) in accordance with and subject to its rules and policies. I understand that not all CBNE policies have been outlined in this application; however, they are listed on www.CBNE.org and are available by contacting the CBNE office. I understand that in making this application, I am bound by all CBNE policies.

  • I understand that it is my responsibility to meet CBNE’s eligibility requirements and to provide such material as is required to document this.

  • I understand that the information acquired in the certification process may be used for statistical purposes and for evaluation of the certification program. I further understand that the information in my records will be treated confidentially.

  • To the best of my knowledge, the information provided in this application is true, complete, correct, and made in good faith. I understand that CBNE reserves the right to verify any and all information on this application and to audit applications during the application process and up to one year thereafter. I understand that any incorrect or misleading information may constitute grounds for rejection of my application, revocation of my certification, or other disciplinary action.

  • I recognize that the CBNE Board is the sole and only judge of my qualifications to receive and to retain a certificate issued by CBNE and to have my name included in any list or directory in which the names of Diplomates of specialty exams are published. I further agree to hold harmless, individually and collectively the officers, directors, staff and appointed examiners of CBNE for any decision or action in pursuance of their duties in connection with this application, the exam, the score or scores given with respect to any exam or for the failure of CBNE to issue me a certificate.

  • I understand and agree that in the consideration of my application my moral, ethical and professional standing may be reviewed and assessed by CBNE; that CBNE may make inquiry of such persons as CBNE deems appropriate with respect to my moral, ethical and professional standing; that if information is received that would adversely affect my application, I will be so advised and given an opportunity to rebut such allegations, but I will not be advised as to the identify of the individuals who have furnished adverse information concerning me; and that all statements and other information furnished to CBNE in connection with such inquiry shall be confidential, and not subject to examination by me or by anyone acting on my behalf.

  • I also pledge myself to the highest ethical standards in the practice of nuclear endocrinology. I fully understand that if I engage in any practice or activity which, in the determination of CBNE is deemed to be in violation of this pledge, that CBNE has full authority to withdraw my certification. Furthermore, I understand that if I engage in any form of exam impropriety before or during the exam, my exam will not be scored. I understand also that, should any impropriety on my part occur, I will not be allowed to re-apply until three (3) years have passed and that a new application and Candidate fees will be required.

  • I understand that CBNE will use electronic mail (email) to communicate with me during the application review and approval process and for all subsequent communications regarding CBNE policies and procedures including, but not limited to exam scheduling and other testing information. If I am unable to receive or send electronic mail I understand I must advise CBNE of an alternate method of communication. I understand that my exam scores and certificate will be the only communications not sent via electronic mail.

I agree to abide by all policies and rules of the Certification Board of Nuclear Endocrinology as posted on www.CBNE.org. I understand that I have the right to request and review any CBNC policy prior to signing this document. I attest that I meet all of the eligibility requirements for certification as outlined on www.CBNE.org