PQ Application Form

ARTP Professional Qualification Application Form

Please complete the form below to apply for the ARTP Practitioner, Associate or Clinical Top Up Professional Qualification.

Please ensure you have read all the FAQS found here before applying.

*Name

*Email

*Job Title / Band

*Name of Trust and Departmental Address

ARTP Membership No (if applicable)

*Qualification Applied for

Relevant Qualifications

(include qualifications currently being taken and state completion date)

*Academic Qualifications

*In Service & Training Qualifications

Relevant Clinical Experience & Referee

*Referee 1 Name

*Referee 1 Email

*Referee 1 Location

*Referee 1 dates from/to

*Referee 2 Name

*Referee 2 Email

*Referee 2 location

*Referee 2 dates from/to

Work Based Supervisor (WBS)

*WBS Name

*WBS Email

*Job Title & Band

*Relevant Qualifications & Experience

*WBS Consent

I can confirm that the person named above has consented to be my Work Based Supervisor

Assessment Information

Practical Examination Equipment choiceCare FusionLoveMedicalMedgraphicsMedisoftNSpireOther (please state below)

Other

Method of measurement for lung volumes choiceBody plethysmographyHelium dilutionNitrogen washout

*Software choice

*Other Equipment Information

Billing Information

*I wish to pay byCredit/Debit CardInvoice - POInvoice - BACS

Payment Information

Pay by Card online - Use a credit or debit card (link will be on the booking confirmation page)
Pay by Invoice with a PO Number - A valid Purchase Order will be accepted as proof of payment
Pay by Invoice to be paid by BACS - You will not be enrolled until the payment is complete

Full Invoicing Address

Invoice Purchase Order / Ref Number (must be supplied)

Finance Email Address

Finance Contact Number

*Confirmation

I can confirm that the information I have provided is correct and that I am eligible to undertake the ARTP Practitioner, Associate or Clinical Top Up examination