Exam Application Candidate Information Fields marked with * are required. Your first and last name must match the name on your government-issued identification. Step 1 of 6 16% First Name (must match your ID):* Middle Initial/Name: Last Name (must match your ID):* Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Home Phone Number:* Email:* Credentials:* AVA Member ID(AVA Membership is NOT required to take the VA-BC™ exam. However, you MUST enter your 8-digit AVA Member ID in order to receive the AVA discount on the exam. If you do not have your 8 digit number please contact AVA at ava@avainfo.org BEFORE submitting this application): Discount Code:(This area is NOT for entry of hospital voucher codes. Applicants with a voucher code will enter it in the blue area on the payment page) Organization/Business:* Job Title:* Business Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type of Application:*Select Test TypeNew Applicant (never taken exam)Retest (previous failed attempt)Recertification by Retest (in lieu of CE option)Certification Number For Recertification OR Retest enter your certification number here. If you don't remember your Certification Number click here. Date(s) of previous exam(s):Require Special Accommodations:* No Yes Hidden I am including a Special Examination Accommodations Request. Candidates requesting special accommodations must submit the Special Accommodations Request Form by mail or fax within 5 business days of applying online, or with a paper application submitted by mail or fax. Keep me informed about VACC business and events:* Yes No By submitting this form I agree to the terms and conditions of the*VACC Privacy Policy: Yes No Fields marked with * are required.Highest Degree:* Certificate Diploma Associate Bachelors Masters Doctorate (MD, DO, PhD, DNP) Other Employment Status:* Full time Part-time Per diem/casual Not currently working Primary Job Function:* Management/Supervisory Education Patient Care Other Primary Patient Population:* Adult Pediatric Adult and Pediatric Adult, Pediatric, Neonatal Neonatal Current Position:* Clinical Nurse Specialist Advanced Practice Nurse Physicians Assistant Physician Practical Nurse/Vocational Nurse Pharmacist Radiologic Technologist Registered Nurse Registered Radiologist Assistant Respiratory Therapist Industry(Medical Science Liaison/clinical specialist/ research and Development) Other Employment Setting:* Hospital/Medical Center Ambulatory Care Skilled Nursing Facility Public Health Care Home Infusion Military Hospice Care Industry/Manufacturer (Clinicians only) Emergency Medical Services Pharmacy Other Who is paying for your certification?* I am paying with my own funds My employer is paying I will be reimbursed by my employer upon successful certification Scholarship How did you hear about the VA-BC™ exam?* Association for Vascular Access Colleague recommendation Job requirement E-mail Facebook LinkedIn Twitter Online search Race: American Indian/Alaska Native Asian Black/African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Caucasian/White Other Do not care to respond Gender: Male Female Age Range: 0-20 21-30 31-40 41-50 51-60 61+ Practice Requirements Eligibility Criteria Certification is open to candidates living in the United States and Canada. Practice in the area of vascular access is required for initial certification. Your current practice in vascular access must use the knowledge and skills described in the content outline. Each candidate should assess their own body of knowledge, skills and understanding of the specialty in deciding when to sit for the exam. All Candidates must: Have a minimum of a post-secondary education Have a minimum of 1 year of professional experience. Practice in the area of vascular access is required for initial certification. Attest they meet one of the following criteria Health Care Professionals in the field of Vascular Access involved in assessing, planning, implementing, and evaluating the care and needs of patients and clients who require vascular access in the course of their care. Professionals working in a field that complements Vascular Access, such as Educators, Administrators, Infection Control Professionals, Nutrition Support Professionals. In addition, your current clinical practice must include at least two (2) of the following activities: Assessing, planning, implementing, and evaluating the care and needs of patients and clients who require vascular access in the course of their care; Education of individuals in best practice as it pertains to vascular access; Development and revision of vascular access policies and procedures; Management of vascular access activities; Provision of consultation of vascular access activities. Self-employed individuals must meet the same practice criteria as above. NameEmail Candidate Application and Confidentiality Statement Fields marked with * are required. All candidates must sign the Candidate Application Statement and agree to all policies, procedures, and terms and conditions of certification in order to be eligible for the VA-BC credential. The statement follows: I have read the current Clinical Practice Requirements and attest that I meet these requirements. I understand that I and the information I have provided could be audited to verify my eligibility. I understand my certification can be delayed until eligibility is verified. I authorize the Vascular Access Certification Board to make whatever inquiries and investigations that it deems necessary to verify my credentials and professional standing. I understand that submission of false or misleading information to VACC or any cheating by me at any time may be cause for withdrawal or revocation of this application without refund of any fees paid, loss of credential (if currently held), cancellation of scores, or denial of eligibility as a candidate to take the exam. I hereby apply for the Vascular Access-Board Certified (VA-BC) credential. I understand that my certification depends on my ability to meet all requirements and qualifications. I certify that the information contained in this application is true, complete, and correct to the best of my knowledge and is made in good faith. I further understand that, if any information is later determined to be false or misleading, or if I have been determined to have cheated in any way, VACC reserves the right to revoke any certification that has been granted on the basis thereof or impose discipline at its discretion. Further, I agree to abide by all VACC policies and procedures, including but not limited to the VACC Code of Ethics and Disciplinary policies and actions. I hereby release, discharge, indemnify, hold harmless, and exonerate VACC, its directors, officers, members, examiners, representatives, affiliates, employees, and agents, from any actions, suits, obligations, damages, claims or demands arising out of, or in connection with, any aspect of the application process including results or any other decision that may result in a decision to not issue me a certificate. I further understand, acknowledge and agree: That the questions and answers of the exam are the exclusive, confidential, proprietary, valuable, copyrighted property of VACC and are protected by the United States Copyright Act and other applicable laws. That I may not disclose the exam questions or answers, in whole or in part, or discuss any content of the exam with any person or in any respect, in any form or media, without prior written approval of VACC, and that I must report to the proctor or to authorized VACC personnel any instances where any other person appears to be violating this nondisclosure rule or to have been cheating in any way. Not to remove from the examination room any exam materials of any kind provided to me or any other material related to the exam, including any notes or calculations. Not to copy or attempt to make copies (written, photocopied or otherwise) of any exam material, any exam questions or answers, or any notes or calculations. Not to sell, license, distribute, give away, or obtain from any other source other than VACC the exam materials, questions or answers. That my obligations in accordance with VACC's requirements shall continue in effect after the examination and, if applicable, after termination of my certification, regardless of the reason or reasons for termination, and whether such termination is voluntary or involuntary. That any and all uses of the VA-BC credential must be consistent with applicable VACC policies and procedures and that unauthorized use or misuse in any way will constitute grounds for disciplinary action, including but not limited to revocation of my credential, legal action, or other action by VACC to protect its valuable intellectual property. I attest that I have reviewed and understand this Handbook and agree to the statements above and to abide by all policies and procedures, including the confidentiality and disciplinary rules, of the Vascular Access Certification Board. I agree that I am subject to the disciplinary policies and procedures of VACC, If applying online I attest to the above by answering "yes",* Yes No I attest that as a new certification candidate, I have at least one year of professional experience and that I currently practice in the area of vascular access. If applying online I attest to the above by answering "yes",* Yes No All candidates MUST provide a supervisor's contact information below. VACC reserves the right to contact your supervisor to verify compliance with our eligibility requirements.Supervisor Name:* Supervisor Title:* Supervisor Email:* Supervisor Phone:* If you have a Voucher Code from your employer please enter it here and click "Enter Code". Otherwise enter your Payment Information below and click "Submit Application". Voucher Code: Payment InformationFields marked with * are required.Exam application Price: Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Billing address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code