Indian Association of Cardiovascular

Thoracic Anaesthesiologists Affix one recent

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Application Form photograph
Perioperative TEE Fellowship Examination (FTEE)
(Jointly by IACTA & University of Minnesota)

(To be filled in block letters)

IACTA Life Membership or IAE membership is mandatory for perioperative TEEexamination

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IACTA / IAE Membership No.:…………………. Attempt (First / Second / Specify)...............................
First name:................................................................................................................................................
Middle name:.................................................................................................................................
Last name:.......................................................................................................................................
Age:................................................ Gender:.......................Date of birth:.....................................
Nationality:....................................................................................................................................
Qualifications: ...............................................................................................................................
Designation: ..................................................................................................................................
Name of the Institution:...................................................................................................................
Institutional address :............................................................................................................................................
.....................................................................................................................................
........................................................... State:............................................ Pincode:
Tel (Res):....................................... Office:.......................................................Fax: . .........................
Mobile:.................................................. Email ID:............................................................................
Address for Correspondence:.....................................................................................................
...........................................................................................................................
State: .................................................................................................Pincode :
PAYMENT OPTIONS:
Demand Draft Favoring IACTA payable at Pune: Mail it to the ICCA office

Cheque (multi city) Remit in any SBI branch to the account number given below and
or Cash mail the counterfoil of the Pay - in-Slip to the ICCA office.

Electronic State Bank of India, PBB, Senapati Bapat Road Branch, Pune
Transfer
(As NEFT) Account No: 30007410621 Account Name: IACTA IFS Code: SBIN0004120

DETAILS OF PAYMENT:

Demand draft Cheque Electronic transfer Cash

D D/ Cheque no :.................................................................... Bank::....................................................................................................
Date of NEFT transfer/cash/cheque Remittance::...........................................................Amount::...................................
Transaction ID/UTR No & Bank (For Electronic transfer) :............................................................................................
Local SBI Branch (Code/Name if applicable) :....................................................... Signature :..........................................
 FTEE examination: guidelines
1. Candidate appearing for the examination must be a Life member of IACTA or Indian Academy
of Echocardiography. IACTA Life membership form is available at www.iacta.co.in

2. (A) Log book of 100 cases, certified by HOD/Mentor (If the applicant is HOD, self-certification is
acceptable)
(B) CD or Pendrive containing TEE loops & images of 25 patients with the name of the candi-
date as the primary echocardiographer. Include only relevant (labelled) loops & images of
each patient. It is advisable to bring your own laptop to demonstrate before the examiners.

3. Examination fee is Rs 10000 for the first attempt. Fee for the second or subsequent attempts is
also Rs 10000. For payment options see above.

4. Candidates who do not appear for the examination will forfeit the amount except under
exceptional circumstances. Students who could not appear due to medical reasons will have
to pay Rs 5000 at the next attempt. Medical reasons given will be verified by the IACTA office.

5. Examination will be conducted during the national TEE workshop-cum-CME at Narayana

Hrudayalaya Bangalore every year.

6. Last date of application is one month before the examination. Last date for cancellation
is two weeks before the examination.

7. Log book format / TEE report form is given in the website.

................................................................... SEND TO ………………………………………….

(Surface mail and Email with scanned copy or details)
Dr. Thomas Koshy
Registrar ICCA
ICCA Office, Anaesthesia House, First Floor,
GCDA Shopping Complex , Panampilly Nagar,
Cochin - 682 036, Kerala, India. Phone: 0484 4011307, Mobile: 9895519551
Email : iccaregistrar@gmail.com Website : www.iacta.co.in

For Office use only

Received date / / DD / Cheque No:................................................Bank:.....................................................

Electronic transfer / Cash / Cheque Remittance details:................................................................................................

Amount:..........................................................Receipt No:.................................................................................................................