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Certification Examination in Neurophysiologic Monitoring for ... Document Transcript

  • 1. CERTIFICATION EXAMINATION IN NEUROPHYSIOLOGIC MONITORING FOR RECERTIFICATION Handbook for Candidates EXAMINATION DATES Winter 2010 Application Deadline Testing Window Begins: February 6, 2010 December 31, 2009 Ends: February 20, 2010 Summer 2010 Application Deadline Testing Window Begins: August 7, 2010 June 30, 2010 Ends: August 21, 2010 American Board of Neurophysiologic Monitoring http://abnm.info 1350 BROADWAY  17th FLOOR NEW YORK, NY 10018 (212) 356-0660 WWW.PTCNY.COM
  • 2. TABLE OF CONTENTS RECERTIFICATION PROCESS ........................................................................- 1 - COMPLETION OF APPLICATION....................................................................- 1 - FEES ............................................................................................................. - 2 - REFUNDS...................................................................................................... - 2 - ADMINISTRATION........................................................................................- 2 - SCHEDULING YOUR EXAMINATION APPOINTMENT ....................................- 3 - SPECIAL NEEDS............................................................................................- 3 - CHANGING YOUR EXAMINATION APPOINTMENT.......................................- 3 - RULES FOR THE EXAMINATION ...................................................................- 3 - REPORT OF RESULTS....................................................................................- 4 - CONTENT OF EXAMINATION........................................................................- 4 - CONTENT OUTLINE.......................................................................................- 4 - SAMPLE EXAMINATION QUESTIONS...........................................................- 9 - REFERENCES .............................................................................................. - 11 -
  • 3. RECERTIFICATION PROCESS Diplomates may apply for recertification within two years prior to the expiration of their certification period by completing an application for recertification. Such application shall be provided by the Board upon request to any Diplomates in good standing at the time of the request. Any certification granted under this process will be for a period of ten additional years. The recertification process will entail retaking a written examination consisting of general questions and questions limited to topics within specialties chosen by the candidate. The time period for application by Diplomates becoming certified before the year 2000 will be extended such that Diplomates certified before the year 2002 will have a two year period in which to recertify beginning August 1, 2009. The examination will contain 250 questions. A minimum of 200 questions must be answered by the recertification candidate. One hundred forty of the 200 questions answered must be correct in order to pass the examination. Should a candidate elect to answer more than 200 questions, the passing score will be 70% correct of the total number of questions answered. The recertification examination will be administered at the same dates and locations as the current written examination is offered. Information concerning applications should be attained from PTC. The recertification fee will be the same as that for the written examination in effect at the time of application. Persons losing their certification by allowing the application window to lapse without successful completion of the exam will be required to complete the original (i.e. written and oral exam) process as a new applicant and will be subject to the new applicant eligibility criteria in place at that time. Any questions concerning this process should be directed to Chair@ABNM.info. COMPLETION OF APPLICATION Complete or fill in as appropriate ALL information requested on the Application. Mark only one response unless otherwise indicated. CANDIDATE INFORMATION: Starting at the top of the Application, print your name, address, E-mail address, daytime phone number, and evening phone number in the appropriate row of empty boxes. ELIGIBILITY AND BACKGROUND INFORMATION: All questions must be answered. Mark only one response unless otherwise indicated. OPTIONAL INFORMATION: These questions are optional. The information requested is to assist in complying with equal opportunity guidelines and will be used only in statistical summaries. Such information will in no way affect your test results. CANDIDATE SIGNATURE: When you have completed all required information, sign and date the Application in the space provided. -1 -
  • 4. APPLICATION CHECKLIST: Candidates must include the following: ___ Completed, signed Application ___ Examination fee Mail in time to be postmarked by the deadline shown on the cover of this handbook to: ABNM Examination PROFESSIONAL TESTING CORPORATION 1350 Broadway – 17th Floor New York, New York 10018 FEES Recertification fee for the Certification Examination in Neurophysiologic Monitoring..........................................................................................$650.00 NOTE: MAKE CHECK OR MONEY ORDER PAYABLE TO: ABNM EXAMINATION Visa, MasterCard, and American Express are also accepted. Please complete and sign the credit card payment form on the Application. REFUNDS There will be no refund of fees. Fees will not be transferred from one testing period to another. ADMINISTRATION All applications for the examination are handled by the designated testing agent of the ABNM, the Professional Testing Corporation (PTC), 1350 Broadway - 17th Floor, New York, New York 10018, (212) 356-0660, www.ptcny.com. The Certification Examination for ABNM for Recertification is administered during an established two-week testing period on a daily basis, Monday through Saturday, excluding holidays, at computer-based testing facilities managed by PSI/LaserGrade Computer Testing, Inc. PSI/LaserGrade has several hundred testing sites in the United States, as well as Canada. Scheduling is done on a first-come, first-serve basis. To find a testing center near you visit: www.lasergrade.com or call PSI/LaserGrade at (800) 211-2754. Please note: Hours and days of availability vary at different centers. You will not be able to schedule your examination appointment until you have received an Eligibility Notice from PTC. ONLINE TUTORIAL AND SAMPLE TEST A Tutorial and a Sample Demonstration Test can be viewed online.  Browse to www.lasergrade.com  Select Test Taker/Candidates menu  Select Testing Software Demo  Select the "General Education Demo Test"  Click on the "Start LaserGrade Online Demo Test" button. This online Tutorial and Sample Test can give you an idea about the features of the testing software. -2 -
  • 5. SCHEDULING YOUR EXAMINATION APPOINTMENT Once your Application has been received and processed, and your eligibility verified, you will be mailed an Eligibility Notice within 6 weeks preceding the start of the testing period. The Eligibility Notice plus current, government- issued photo identification must be presented in order to gain admission to the testing center. A candidate not receiving an Eligibility Notice at least three weeks before the beginning of the testing period should contact the Professional Testing Corporation by telephone at (212) 356-0660 with their fax number. The Eligibility Notice will indicate where to call to schedule your examination appointment as well as the dates in which testing is available. Appointment times are first-come, first-serve, so schedule your appointment as soon as you receive your Eligibility Notice in order to maximize your chance of testing at your preferred location and on your preferred date. It is highly recommended that each candidate becomes familiar with the testing site. It is the candidate’s responsibility to call PSI/Lasergrade to schedule the exam appointment. SPECIAL NEEDS Special testing arrangements may be made for individuals with special needs. Submit the Application, examination fee, and a completed and signed Request for Special Accommodations Form, available from www.ptcny.com or by calling PTC at (212) 356-0660. Requests for individuals with special testing needs must be received at least EIGHT weeks before the testing period begins. CHANGING YOUR EXAMINATION APPOINTMENT If you need to cancel your examination appointment or reschedule to a different date within the two-week testing period you must contact PSI/LaserGrade at (800) 211-2754 no later than noon, Eastern Standard Time, of the second business day PRIOR to your scheduled appointment. RULES FOR THE EXAMINATION 1. No signaling devices, including pagers, cellular phones, and alarms, may be operative during the examination. 2. No books or reference materials may be taken into the examination room. 3. Simple, nonprogrammable calculators are permitted with the exception of calculators as part of cellular phones, blackberries, etc. A calculator is also available on screen if needed. 4. No questions concerning content of the examination may be asked during the testing period. The candidate should read carefully the directions that are provided on screen at the beginning of the examination session. -3 -
  • 6. REPORT OF RESULTS Candidates will be notified in writing within six weeks whether they have passed or failed the examination. Scores on the major areas of the examination and on the total examination will be reported. The ABNM will release the individual test scores ONLY to the individual candidate. Any questions concerning test results should be referred to the Professional Testing Corporation. If there are questions about the overall process or problems that cannot be resolved with PTC, please contact the ABNM. CONTENT OF EXAMINATION The following weightings are used to distribute the questions on the Certification Examination in Neurophysiologic Monitoring for Recertification: I. BASIC NERUOSCIENCE .................................................. ….…….30% II. SIGNAL ACQUISTION AND PROCESSING ........................................8% III. ELECTROENCEPHALOGRAPHY (EEG) .............................................10% IV. SENSORY EVOKED POTENTIALS..................................... ….…….22% V. MOTOR POTENTIALS.....................................................................22% VI. EFFECTS OF ANESTHESIA...............................................................8% The examination will contain 250 questions. A minimum of 200 questions must be answered by the recertification candidate. One hundred forty of the 200 questions answered must be correct in order to pass the examination. Should a candidate elect to answer more than 200 questions, the passing score will be 70% correct of the total number of questions answered. The recertification examination will be administered at the same dates and locations as the current written examination is offered. Information concerning applications should be attained from PTC. The recertification fee will be the same as that for the written examination in effect at the time of application. CONTENT OUTLINE I. BASIC NEUROSCIENCE A. Neuroanatomy 1. Neural Pathways a. Sensory Modalities and Pathways b. Motor Pathways c. Other 2. Peripheral Nerve a. Plexi b. Nerve Roots 3. Spine a. Bony Structures b. Ascending Tracts c. Motor Tracts d. Spinal Circulations e. Cauda Equina f. Dermatomal Distribution g. Myotomes h. Spinal Cord 4. Brainstem a. Vascular Anatomy b. Neuroanatomy 5. Cerebral Hemispheres -4 -
  • 7. a. Primary Motor Area b. Primary Sensory Area c. Vascularity 1. Internal Carotid Artery 2. Circle of Willis 3. Anterior Cerebral Artery 4. Middle Cerebral Artery 5. Posterior Cerebral Artery d. Association Cortex 6. Cranial Nerves Pathways and Function 7. Ear/Auditory Pathway 8. Eye/Optic Pathway 9. Muscles 10. Blood Supply a. Cortex b. Brainstem c. Spinal Cord 11. Skull B. Neurophysiology 1. Membrane Electrical Potential 2. Propagated Neural Activity 3. Synaptic Transmission 4. Reflexes II. SIGNAL ACQUISITION AND PROCESSING A. Basic Electrical Concepts B. Recording and Stimulation Technique 1. Artifact/Noise 2. Electrodes 3. Amplifiers 4. Filtration a. Analog Filters b. Digital Filters c. 60 Hz Notch Filter 5. Averager Technology 6. Data Storage and Record Keeping 7. Medical Legal Records a. Chart Documentation b. Consent Forms C. Safety Issues D. Troubleshooting E. Transcranial Doppler III. ELECTROENCEPHALOGRAPHY (EEG) A. Generators B. Interpretation C. Classification of Frequency D. Recognition of Patterns 1. Electrocerebral Silence 2. Alpha Rhythm 3. Burst-Suppression 4. Seizure Activity 5. Ischemia 6. Hyperthermia/Hypothermia 7. Changes in Ventilation 8. Artifact -5 -
  • 8. E. Recording Montages F. Methods of EEG Processing 1. Fourier Series Analysis 2. Bispectral Array 3. Mapping Techniques G. Electrocorticography H. Functional Mapping 1. Sensory 2. Motor 3. Subcortical I. Surgical Procedures 1. Carotid Endarterectomy 2. Seizure Surgery 3. Cardiac Surgery 4. Deliberate Hypothermia 5. Deliberate Hypotension 6. Barbiturate Coma 7. Intracranial Vascular Procedures IV. SENSORY EVOKED POTENTIALS A. Somatosensory Evoked Potentials 1. Stimulation a. Peripheral Nerve b. Spinal Cord 2. Monitoring Technique a. Recording Montages b. Recording Parameters c. Peak Identification and Correlation with Neural Generators 3. Surgical Procedures a. Cerebrovascular b. Identification of Central Sulcus c. Brainstem Procedures d. Extracranial Vascular e. Spinal f. Peripheral Nerve g. Other 4. Nonsurgical Factors a. Temperature b. Blood Pressure c. Cerebral Blood Flow d. Intracranial Pressure e. Oxygenation f. Patient Positioning B. Brainstem Auditory Evoked Potentials 1. Stimulation 2. Monitoring Technique a. Recording Montages 1. Noninvasive 2. Invasive Techniques b. Recording Parameters c. Peak Identification and Neural Generators 3. Surgical Procedures Where Used a. Cerebellopontine Angle Tumors b. Microvascular Decompression c. Vestibular Neurectomy d. Brainstem Procedures -6 -
  • 9. e. Other 4. Nonsurgical Factors a. Middle Ear Pressure b. Fluid from mastoid c. Temperature d. Blood Pressure e. Intracranial Pressure f. Oxygenation g. Other C. Visual Evoked Potentials V. MOTOR POTENTIALS A. Cranial Motor Nerve Monitoring 1. Stimulation a. Electrical b. Nonelectrical 2. Monitoring Techniques a. Recording Montages b. Recording Parameters c. Identification of Specific Cranial Nerves 3. Surgical Procedures a. Skull Base Tumors b. Other B. Central Motor Evoked Potentials 1. Stimulation a. Transcranial Electric b. Transcranial Magnetic c. Spinal Cord Stimulation d. Direct Cortical Stimulation 2. Monitoring Techniques a. Recording Montages b. Recording Parameters c. Peak Identification and Neural Generators 3. Surgical Procedures a. Spine b. Other C. Peripheral Nerve System 1. Stimulation 2. Monitoring Techniques a. Recording Montages b. Recording Parameters 3. Surgical Procedures a. Pedicle Screws b. Dorsal Rhizotomy c. Peripheral Nerve d. Brachial Plexus e. Other 4. Nonsurgical Factors a. Temperature b. Tourniquet -7 -
  • 10. VI. EFFECTS OF ANESTHESIA A. Agents 1. Inhalational a. Halogenated b. Nitrous Oxide 2. Intravenous a. Opioids b. Sedatives-Hypnotics 3. Muscle Relaxants 4. Regional Anesthesia 5. Formulas for Dosage B. Differential Effects on Anatomic Structures 1. Muscle 2. Neuromuscular Junction 3. Peripheral Nerve 4. Spinal Cord 5. Brainstem 6. Cortex C. Anesthetic Techniques 1. Suitable for Various Recordings a. Cortical Recording b. Subcortical Recording c. Muscle Action Potential Recording d. Cortical Stimulation Techniques e. Direct Cortical Stimulation f. Transcutaneous Motor Stimulation 2. Wake Up Test 3. Management of Neuromuscular Block 4. Patient Positioning D. Physiological Factors 1. Temperature 2. Metabolites, Electrolytes 3. Intracranial Pressure 4. Oxygenation 5. Blood Pressure/Perfusion 6. Ventilation -8 -
  • 11. SAMPLE EXAMINATION QUESTIONS In the following questions, choose the one best answer. 1. What is the most prominent EEG characteristic of isoflurane at low- moderate concentrations? 1. Isoelectricity 2. Selective delta loss 3. Burst-suppression activity 4. Power peaks within the 8-12 Hz band 2. The ascending fibers of the cuneate nucleus and gracilis nucleus cross over in the medulla to form what structure? 1. Internal capsule 2. Lateral lemniscus 3. Medial lemniscus 4. Superior colliculus 3. Which of the following anesthetic agents can increase SEP amplitudes? 1. Etomidate 2. Isoflurane 3. Midazolam 4. Nitrous oxide 4. When stimulating the median nerve, an electrode placed at Erb’s point will record activity generated from 1. cauda equina. 2. lumbar plexus. 3. brachial plexus. 4. thalamocortical radiations. 5. Quantitization error resulting in the failure to resolve the true primary complex of the evoked response is due to 1. sampling too slow a rate. 2. using too narrow a bandwidth. 3. using too low a gain for the system’s A-to-D input. 4. using too high a gain for the system’s A-to-D input. -9 -
  • 12. 6. What is the proposed generator of Wave I of the BAEP? 1. Superior olive 2. Inferior colliculi 3. Auditory cortex 4. Distal auditory nerve 7. The facial nerve is being monitored during an operation for an acoustic tumor recording EMG potentials from electrodes on the face placed at long distance from each other. The surgeon is probing the surgical field with a monopolar handheld stimulating electrode. Clear responses are observed from one location and a clear response from another but no response from other locations of the surgical field. The latency of the EMG response is different, short when one location is stimulated and long when the other location is stimulated. From where do these responses most likely come? 1. Both responses from the facial nerves 2. Both responses from the trigeminal nerve 3. The response with the long latency from the facial nerve and the response with the long latency from the trigeminal nerve 4. The response with the short latency from the facial nerve and the response with the long latency from the trigeminal nerve 8. The P100 from the visual evoked potential stimuli is thought to be generated by the 1. retina. 2. optic nerve. 3. optic chiasm. 4. occipital cortex. CORRECT ANSWERS TO SAMPLE QUESTIONS 1. 4 2. 3 3. 1 4. 3 5. 3 6. 4 7. 3 8. 4 - 10 -
  • 13. REFERENCES Preparing for the examination is made challenging by the nature of the question development process since the material does not come from one specific source. Although each question author was asked to provide a reference for the question origin (and to verify the correct answer), the wide and diverse capture of questions from numerous individuals in the field has led to an enormous database of question references. Further, since the questions went through a thorough and rigorous editing and updating process, many of these references have changed to more current references that reflect the changing nature of the field. Further, the examination is continually updated so that each examination will add new questions to stay current and accurate with the scope of monitoring practice. As such, no single reference can be used to prepare for the examination, but instead the Board recommends the following set of textbooks and journals as references for preparation. Note that journals will help fill the gap from knowledge contained in textbooks. Textbooks (alphabetical order by author): 1. M. J. Aminoff, Electrodiagnosis in Clinical Neurology, 5th Edition, Elsevier, 2005. 2. D.L. Beck, Handbook of Intraoperative Monitoring, Singular Publishing Group, Inc., 1994. 3. E.E. Benarroch Medical Neurosciences: An Approach to Anatomy, Pathology, and Physiology by Systems and Levels, 4th Edition, Lippincott Williams & Wilkins Publishers, 1998. 4. K. K. Chiappa Evoked Potentials in Clinical Medicine, Lippincott Williams & Wilkins, 3rd Edition, 1997. 5. D.D. Daly, T.A. Pedley, Current Practice of Clinical Electroencephalography, 2nd edition, Raven Press, 1990. 6. V. Deletis, J. Shils, Neurophysiology in Neurosurgery. A Modern Intraoperative Approach, Academic Press, 2002. 7. JE Desmedt, Neuromonitoring in Surgery (Clinical Neurophysiology Updates, Volume 1, Elsevier Science Ltd., 1989. 8. J. Engel, Surgical Treatment of the Epilepsies, 2nd Edition, Raven Press, 1993. 9. R.H. Gelberman, Operative Nerve Repair and Reconstruction, Lippincott Raven, 1991. 10. B.L. Grundy, RM Villani, Evoked Potentials: Intraoperative and ICU Monitoring, Springer Verlag, 1988. 11. E.R. Kandel, J.H. Schwartz, T.M. Jessell, Principles of Neural Science, 4th Edition, McGraw-Hill, 2000. 12. C.M. Loftus, V.C. Traynelis, Intraoperative Monitoring Techniques in Neurosurgery, McGraw-Hill, 1994. 13. K.F. Misulis, Spehlmann’s Evoked Potential Primer, 3rd Edition, Butterworth-Heinemann, 2001. - 11 -
  • 14. 14. A. Möller, Intraoperative Neurophysiological Monitoring, Second Edition, Humana Press, 2006. 15. E. Niedermeyer, F.L. Da Silva, Electroencephalography: Basic Principles, Clinical Applications and Related Fields, 5th Edition, Lippincott, Williams and Wilkins, 2005. 16. M.R. Nuwer, Intraoperative Monitoring of Neural Function, Elsevier Press, 2008. 17. G.B. Russell, L.D. Rodichok, Primer of Intraoperative Neurophysiologic Monitoring, Butterworth-Heinemann Press, 1995. 18. B.F. Westmoreland and E.E. Benarroch, Medical Neurosciences: An Approach to Anatomy, Pathology and Physiology by Systems and Levels, 3rd Edition, Lippincott Williams and Wilkins, 1994. 19. L. Wilson-Pauwels, PA Stewart, E.J. Akesson, Cranial Nerves, BC Decker, Inc., 1998. 20. G. Zouridakis, A.C. Papanicolaou, A Concise Guide to Intraoperative Monitoring, CRC Press, 2001. Suggested Journals (alphabetical order): 1. American Journal of Otology 2. Clinical Neurophysiology 3. Journal of Clinical Neurophysiology 4. Journal of Neurophysiology 5. Journal of Neuroscience 6. Journal of Neurosurgery 7. Neurosurgery 8. Spine 9. Spine Journal Other than these suggestions, the ABNM currently does not endorse any particular review course or study guides. Further, other than reviewing the publicly available material (such as this information sheet), the active directors of the ABNM Board have agreed to refrain from participating in courses specifically designed to review or prepare for the examination. Individuals who have taken the written examination have made the following comments. Individuals typically used all of the time available. When asked about giving advice for studying for the examination these individuals suggested the following. Particularly helpful texts were Desmedt and Chiappa for basic electrophysiology. Review basic neuroanatomy, especially the cranial nerves. For this, the works by Netter were recommended. Review Marc Nuwer's book for basic technology and recording methodology and review Aage Moller's book for auditory monitoring. Review the Journal of Clinical Neurophysiology for current reviews as well as examine the current material presented at up-to- date meetings (such as the annual ASNM meeting) was helpful and in line with the material on the exam. PTC09200 - 12 -
  • 15. Application for Certification Examination in Neurophysiologic Monitoring for Recertification Please read the directions in the Handbook for Candidates carefully before completing this Application. MARK ING INSTRUCTIONS: This form will be scanned by computer, so please make your marks heavy and dark, filling the circles completely. P lease print uppercase letters and avoid contact with the edge of the box. See example provided. Candidate Information Last Name First Name Middle Initial Number and Street Apartment Number City State/Province Zip/Postal Code E-mail Address Daytime Phone Evening Phone - - - - ABNM Certification Information Certificate Number Date of Initial Date Certificate Certification Expires Month Year Month Year Eligibility and Background Information Darken only one choice for each question unless otherwise directed. A. HIGHEST ACADEMIC DEGREE: F. PRIMARY HOSPITAL WHERE CASES ARE Master's MD MONITORED:(Darken only one response.) PhD Other (specify) ________________ Academic practice Children's hospital Private hospital (urban) Veteran's Admin. hospital B. DO YOU HOLD ANY OTHER PROFESSIONAL CERTIFICATION? Private hospital (rural) Other (specify) ___________ No Yes G. CHARACTER OF EMPLOYMENT:(Darken only one If yes, please specify: ______________________________ response.) C. YEARS OF EXPERIENCE DABNM: Hospital based Physician group 8 to 10 11 to 15 16 to 20 Over 21 Private practice Monitoring company Academic practice Other (specify) _____________ D. NUMBER OF CASES SUPERVISED ANNUALLY: 1 to 400 801 to 1200 H. PERCENT OF WORKING TIME SPENT IN 401 to 800 Over 1200 INTRAOPERATIVE MONITORING: Less than 25% 51 to 75% E. PERCENT OF CASES IN DIFFERENT REGIONS OF THE 26 to 50% Over 75% NERVOUS SYSTEM: I. NUMBER OF MONITORING TECHNICIANS % Spine SUPERVISED AT ONE TIME: None 1 to 5 6 to 10 Over 10 % Cranial Nerve J. DO YOU PARTICIPATE IN: (Darken all that apply.) % Brainstem Training of DABNM candidates Training of Monitoring Technicians % Peripheral Nerve/Plexus Teaching of Undergraduate Courses % Cortical Teaching of Graduate Courses (Complete Page 2) 15670 ABNM, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC09201
  • 16. Application for Certification Examination in Neurophysiologic Monitoring for Recertification Eligibility and Background Information Page 2 K. PROFESSIONAL BACKGROUND: Neurophysiology/Neuroscience Neurosurgery Anesthesia Orthopedics Audiology Chiropracter Neurology Other (specify) ________ Otolaryngology L. HAVE YOU TAKEN THIS EXAMINATION BEFORE? No Yes If y e s , in d ic a te m o n th , y e a r, a n d n a m e u n d e r wh ic h th e e x a m in a tio n wa s ta k e n . Date (month/year): Name: Optional Information Note: Information related to race, age, and gender is optional and is requested only to assist in complying with general guidelines pertaining to equal opportunity. Such data will be used only in statistical summaries and in no way will affect your recertification. Race: Age Range: Gender: African American Native American Under 25 40 to 49 Male Asian White 25 to 29 50 to 59 Female Hispanic Other 30 to 39 60+ Candidate Signature COMPLETE ENTIRE APPLICATION BEFORE SIGNING BELOW. I have read the Handbook for Candidates and understand that I am responsible for knowing its contents. I certify that the information given in this Application is in accordance with Handbook instructions and is accurate, correct, and complete. CANDIDATE SIGNATURE: DATE: CREDIT CARD PAYMENT FOR OFFICE USE ONLY If you want to charge your application fee on your credit card provide all of the following information. Date Name (as it appears on your card): Address (as it appears on your statement): Charge my credit card for the total fee of: $ Expiration date (month/year): Fee: / Card type: Visa MasterCard American Express CC Check Card Number: Signature: 15670 ABNM, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC09201