Application for the Fellowship Program Title*Please selectDrMissMrsMsMrFirst Name*Last Name*ACPAN Membership Number*AHPRA Registration Number*Email* Enter Email Confirm Email Phone*State of Residence*NSWVICQLDSAWATASNTACTPlease upload your post graduate certificate and transcripts here:*Do you have a minimum 2 years full time (or part time equivalent and 1 year full-time equivalent hours in anaesthesia) experience and are currently employed in a perianaesthesia field?*YesNoDo you understand that you are responsible for the expense and any additional costs of the ACPAN Clinical Fellowship program?*YesNoAdult Advanced Life Support and Paediatric Advanced Life SupportIn which city would you prefer to complete ALS/ PALS courses as part of the ACPAN Clinical Fellowship?*SydneyMelbourneBrisbaneFellowship Program Requirements• Do you understand that in order to successfully apply for the ACPAN Clinical Fellowship program you must meet the following requirements:*(1) Financial Membership of ACPAN; (2) Registered Nurse (Div. 1), registered with AHPRA; (3) Credentialed at Level 1 ACPAN Education Curriculum; (4) Currently employed in the Peri-Anaesthetic environment (Anaesthetics and PACU); (5) Minimum 2 years full-time (or the equivalent part-time) experience in Anaesthetics and PACU with 1 of those years consisting of full- time (or the equivalent part-time) experience in Anaesthetics; and Currently employed in the Peri-Anaesthetic environment (Anaesthetics and PACU); (6) PeriAnaesthesia post graduate qualification or equivalent as per ACPAN Level 2 Education Curriculum.(Anaesthetics and PACU); Yes, I agreeNo, I do not agreeDo you understand that by electing to undertake the oral viva, and attend the Award Ceremony at the ACPAN National Conference you will be required to be in attendance in the National Conference host city for up to 4 consecutive days and that any expenses incurred are your own responsibility?*YesNoPlease upload your CV here*Do you understand that by submitting your application, you are acknowledging you have read, and accept, the terms and conditions of the ACPAN Clinical Fellowship program.*YesNoClick here to view the terms and conditions.