EDAIC Part I 2016 - Application form for WARSAW Part I centre

Candidates for the EDAIC Part I using this Excel sheet must be applying for the EDAIC Part I 2016 examination in Warsaw. They can but do not need to be registered in the Polish medical register.
Candidates not registered in the Polish medical register must however send a copy of their medical diploma with this application form. If their diploma is not written in one of the languages used for EDAIC Part I or Part II, such candidates must also send a certified English translation of their diploma.
Polish candidates wishing to register for another centre can do so through the ESA website at the full registration rate (295 Euro).
In case of doubt, candidates registering for the EDAIC Part I examination with the intention of applying for the EDAIC Part II examination later should contact exam@esahq.org to check their eligibility for the EDAIC Part II before registering for the EDAIC Part I.
Please give all details requested on row 6. All fields are mandatory except for the ESA membership number, which is optional. Please do not try to alter the format of any of the cells of this form as this could incur problems during the import of your data. Please use capital letters only when relevant.
The registration rate for the EDAIC Part I in Warsaw is 150 Euro per candidate registered as a doctor in Poland. The registration rate for the EDAIC Part I in Warsaw is 295 Euro per candidate not registered as a doctor in Poland.
All information about your examination will be sent to you by the ESA BY E-MAIL, including your results. Please make sure to give one personal and valid e-mail address, and to add the address exam@esahq.org to your list of accepted contacts.
By filling in this form, you confirm that you agree with all the EDAIC Part I regulations posted on the ESA website.
Please make sure to read all documents related to EDAIC Part I on the ESA website, including the sample of 120 questions available for download (Diploma Guide, How to prepare for the EDAIC, Sample questions, MCQ Instructions, Sample Answer sheet, Part I Regulations, Recommended Reading list).
If you do not live in Poland, please make sure to have a valid passport for Poland for the time of your examination if needed.
Deadline to send this form back to your Society: 18 May 2016.

PERSONAL AND CONTACT DETAILS PRIVATE ADDRESS EXAMINATION DETAILS

ESA Membership N° First Name

Last Name Date of Birth Valid Personal E-Mail Address
(made of 6 digits; as written on your Title Mobile phone Nationality Street Street n° Postal Code City Country Examination Language
as written on your passport (dd/mm/yyyy) (very sensitive; please double-check this field)
only if applicable) passport

END OF APPLICATION FORM - PLEASE SUBMIT TO THE POLISH REGISTERING NATIONAL AUTHORITY AS INSTRUCTED ON THE PTAiIT WEBSITE WHEN DULY FILLED IN