FESAIC Application Form

Title(Required)

Name(Required)

First Last

Email(Required)

Job Title

ESAIC ID Number

Mailing Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Choose a pathway(Required)

Pathway 1 (Minimum 5-year Active Membership)

Pathway 2 (Minimum 2-year EDAIC Holder and 2-year Active Membership)

Qualification Criteria

IMPORTANT NOTE
Pathway 1: You need to select at least 6 qualification criteria (minimum 1 qualifier from each category)
Pathway 2: You need to select at least 3 qualification criteria (minimum 1 qualifier from each category)

Professionalism/Leadership(Required)

Select all that you qualify for.

Leadership position or participation in an ESAIC committee, task force, or other ESAIC entity

Local or community leadership position or activities

Hospital or practice leadership position

Held a leadership position with a subspecialty or any medical society

Demonstrated medical volunteerism

Patient Safety and Quality(Required)

Select all that you qualify for.

Attended an ESAIC Patient Safety Masterclass

Active participation in ESAIC Patient Safety and Quality Committee (PSQC)

Active participation in ESAIC Patient Safety Policy Summit or ISQ

Other proof of involvement in Patient Safety

Education/Scholarly Activities(Required)

Select all that you qualify for.

Active involvement in teaching or mentoring activities

Research in anaesthesiology and/or intensive care

Publication in a peer-reviewed journal or journals

EDAIC examiner or exam program development

Education program or material development

Faculty position at Euroanaesthesia or other educational programs, webinars, or annual meetings

Editor position for publications

Subspecialty or other medical board certification

Please explain in detail how these qualifiers apply to you.(Required)

Please attach your CV & Bibliography, 2 Endorsements and any other supporting documents.(Required)

Drop files here or

Max. file size: 8 MB.

Once you have submitted your application, you will need to login to my.esaic.org to complete the payment process.

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