Application for the EHRA EP Recognised Training Centres

Contact Person*

The name will be published on our website next to the Training Centre's name

ESC ID of the contact person*

The contact person should create its own account via MyESC platform providing clear, valid and complete contact details: https://escol.escardio.org/MyESC/modules/User/register_step1.aspx

Contact person email address*

The e-mail will be published on our website next to the Training Centre's name

Name of the Centre*

City of the Centre*

Country of the Centre*

Select or enter value

Website (if any)

Phone number*

Please indicate is the Centre is*

Select

Please indicate the type of the Centre*

Select or enter value

Please describe the training facilities and expertise of the Centre (100 to 150 words max)*

I. Centre Staff Requirements

1.a. Please confirm that in your Centre you have two Senior Electrophysiologists who are EHRA Members of the current year*

Yes

1.b. Full name of the EHRA Member 1*

1.c. ESC ID of the EHRA Member 1*

1.d. Full name of the EHRA Member 2*

1.e. ESC ID of the EHRA Member 2*

2. Please confirm that the above mentioned two Senior Electrophysiologists will renew automatically their EHRA Membership for the next 4 years*

Yes

3.a. Please confirm that at least one of your Staff Members has successfully completed the EHRA Exam for Electrophysiology*

If not certified please answer 3.d.

Yes

3.b. Full name of an EHRA Certified EP

3.c. ESC ID of an EHRA Certified EP

3.d. If not certified, please provide the name of one person within your department who will sit for the exam within the next five years*

4.a. Please confirm that the EP Programme Director of your Centre is an EHRA Member too and has more than 5 years experience in cardiac EP*

Yes

4.b. Full name of your Programme Director*

4.c. ESC ID of your Programme Director*

4.d. Fellow fulfil requirements of EHRA Logbook*

II. Centre Participation Requirements

5.a. Please confirm if the number of Fellows in the Centre allows each Fellow to fulfil the requirements of the EHRA logbook for certification in 2 years*

Yes

5.b. Please confirm that the Centre allows its enrolled Fellows to visit at least one EHRA event (endorsed course, meeting, EHRA congress, etc.) per year*

Yes

5.c. Please confirm that the Centre will encourage its enrolled Fellows to pass the EHRA certification exam*

Yes

III. Information about Centre

6.a. Invasive Cardiac Electrophysiology : 200 pro.

Select or enter value

6.b. Fellows able to perform 1st operator >50 ab

Select or enter value

6.c. Number of procedures availability 3D mapping

Select or enter value

6.d. Number of procedures LA ablations >50

Select or enter value

6.e. Number of procedures VT ablations >20

Select or enter value

IV. Center Fellows' Participation Requirements

Please provide the name and contact information of at least two Fellows which has been trained at your Centre for the past four years for reference. * TF = Training Fellowship

Fellow 1 Title*

Select or enter value

Fellow 1 Full name*

Fellow 1 E-mail*

Fellow 1 TF* starting date*

Fellow 1 TF* ending date*

Fellow 2 Title*

Select or enter value

Fellow 2 Full name*

Fellow 2 E-mail*

Fellow 2 TF* starting date*

Fellow 2 TF* ending date*

Fellow 3 Title

Select or enter value

Fellow 3 Full name

Fellow 3 E-mail

Fellow 3 TF* starting date

Fellow 3 TF* ending date

Fellow 4 Title

Select or enter value

Fellow 4 Full name

Fellow 4 E-mail

Fellow 4 TF* starting date

Fellow 4 TF* ending date

File Attachments

Drag and drop files here or

Billing information

Please indicate the billing address that you want to see on the invoice. If you have a VAT number and if you need a PO (Purchase Order) number on the invoice, please indicate them in the fields below. WARNING : Please note that the invoice will be edited and sent only ONCE. So make sure that all the billing information are correct. No invoice modification will be made. Thank you.

Billing address*

VAT number

Purchase Order number

Acceptance and Conditions

PERSONAL DATA PRIVACY The information collected is subject to a computerized process to record, and track your Centre application. The recipients of the data are : - The staff in charge of processing "EHRA Recognised Training Centre" applications - Persons to whom the request will be sent for review and evaluation In accordance with the French law N°78-17 of January 6,1978, amended in 2004, relating to the protection of individuals with regard to the processing of personal data, you have the right to access and rectify information concerning you, which you can exercise by contacting : Customer Services European Society of Cardiology Les Templiers, 2035 Route des Colles CS 80179 Biot 06903 SOPHIA ANTIPOLIS CEDEX. FRANCE You can also, for legitimate reasons, oppose the processing of data about you.

I confirm that I have read and answered accurately and correctly the EHRA Recognised Training Centres requirements to the best of my knowledge and belief.*

Yes

Send me a copy of my responses

Privacy Notice|Report Abuse