EXIT Exam OF IAPM Fellowship – 2021 Sign up Form

You must read the Guidance Notes & Regulations (Click Here To Download) before completing this form

Last Date for the Submission of the Application form is: 30th December 2021

Fill the Below Form and apply for FIAPM – Exit Exam

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FIAPM - Exit Exam Application Form

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First Name

Surname / Family Name ( as it appears in the Medical Council Registration)*

Gender*

Male

Female

Date Of Birth* ×

ISSP Life Membership number*

Medical Council Registration Number*

State Where registered*

Address*

Recipient

Address line one

Address line two

Address line three

Country

Province

Postal Code

Phone*

Email Address

Please provide the dates of previous attempts at FIAPM

Please specify which one of the following applies to you *

I am currently an IAPM trainee

I have completed pain training in an Indian University accredited programme

I have completed an accredited pain training overseas

I have completed pain training from a private institution

I am a senior Physician

For supporting documents please refer to Guidance Notes & Regulations 14.1 to 14.9

For examination fee refer to guidelines Notes & Regulations 5.4

Declaration

I certify that:

All the statement in this application are true
I have read and agree to abide by the IAPM examination Regulations.
I am eligible in all respects to enter this examination.I have no illness or disability that would preclude the safe practice of pain medicine, including dependence on or inappropriate use of alcohol or recreational and/or non-prescribed drugs, and/or treatment with prescribed drugs likely to compromise the safe practice of pain medicine.

Signature

Date ×

Please consult the accompanying Guidelines notes & Regulations for further information.

Supporting Document Required

1) Medical Council Registration *

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2) Postgraduate Certificate (MD/DA/DNB) *

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3) Quarterly Training Assessment Forms and summary of logbook signed by the Programme Head *

(IAPM trainees only)

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4) Letter of completion of training in pain medicine (Optional)

(to be submitted by all applicants, except IAPM trainees and senior pain physicians)

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5) Letter confirming a pass in the exit exam for pain medicine (Optional)

(to be submitted by all applicants, except IAPM trainees and senior pain physicians)

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6) Letter of recommendation from ISSP or IAPM Governing Council member*

(Senior pain Physicians only)

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7) Proof of publication. Two most recent publications*

(Senior Pain physicians only)

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EXIT Exam OF IAPM Fellowship – 2021 Sign up Form

Upload Photo *

Address*

Declaration

Signature

Supporting Document Required

1) Medical Council Registration *

2) Postgraduate Certificate (MD/DA/DNB) *

3) Quarterly Training Assessment Forms and summary of logbook signed by the Programme Head *

4) Letter of completion of training in pain medicine (Optional)

5) Letter confirming a pass in the exit exam for pain medicine (Optional)

6) Letter of recommendation from ISSP or IAPM Governing Council member*

7) Proof of publication. Two most recent publications*

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