NCCSA » Certification Application

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I am applying for the following category:*
Required Documents
Please submit your form with the following required documents by uploading them below.
Experience Affidavit (PDF)
Accepted file types: pdf, Max. file size: 64 MB.
You can fill out the Experience Affidavit, scan, and upload it here.
Skills Affidavit (PDF)
Accepted file types: pdf, Max. file size: 64 MB.
You can fill out the Skills Affidavit, scan, and upload it here.
Copy of current certification/license if applicable
Accepted file types: pdf, jpeg, jpg, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG
Graduate Certificate
Accepted file types: pdf, jpeg, jpg, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG
Proof of formal SA training
Accepted file types: pdf, jpeg, jpg, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG
Letter of recommendation from Surgeons you have assisted (1)
Accepted file types: pdf, jpeg, jpg, doc, docx, txt, rtf, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG, Word Document
Letter of recommendation from Surgeons you have assisted (2)
Accepted file types: pdf, jpeg, jpg, doc, docx, txt, rtf, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG, Word Document
Letter of recommendation from Surgeons you have assisted (3)
Accepted file types: pdf, jpeg, jpg, doc, docx, txt, rtf, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG, Word Document
Documentation of 140 surgical procedures in the role of surgeon and/or surgical assistant. A minimum of 20 cases must be performed in general surgery, with the remaining cases divided between at least two specialties. A minimum of 20 cases must be completed in each of the two specialties selected.
Accepted file types: pdf, jpeg, jpg, doc, docx, txt, rtf, Max. file size: 64 MB.
Accepted Formats: PDF, JPEG, JPG, Word Document
For FMG applicants: All applicants who entered the U.S. after the age of 12, have a foreign degree and/or English as a second language are required to provide TOEFL exam results. This requirement must be fulfilled before your application will be considered complete and eligible for review.
Accepted file types: pdf, jpeg, jpg, doc, docx, txt, rtf, Max. file size: 64 MB.
Due to the importance of communication in the English language for both learning and practicing, further demonstration of English proficiency may be requested as a condition of acceptance for applicants exhibiting difficulty with the written or spoken language. To ensure an ability to function at the professional level in this healthcare environment, the following are acceptable TOEFL scores:  Internet-based test (preferred): 85  Computer-based test: 220  Minimum of 25 in the speaking component
Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Fax
Current Employer
Employer/Company Name*
Employer/Company Address*
Street Address Address Line 2 City State ZIP Code
Employer Phone
Employer Fax
How Long Have You Been Assisting?*
How Long Have You Been Employed At This Job?*
Immediate Supervisor
Supervisor's Phone
Education and Training
*
Name of Program Location of Program Dates Attended Degree/Certificates Awarded
Previous Employment
Position Held
Date Position Held
Employer/Company Name
Employer/Company Address
Street Address Address Line 2 City State ZIP Code
Employer/Company Phone Number
Direct Surpervisor
Fees
The following fees are associated with your application. Certification application fees are non-refundable.
MD/DO $100
Price:
Graduate from a CAAHEP Accredited SA Educational Program $100.00
Price:
New Graduate (graduated within last 12 months) $50
Price:
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address City State ZIP Code
Total
$0.00
Your card will be charged this amount.
Rules and Regulations*
- I agree
By submitting this form you agree to the rules and regulations and the Ethical Standards of the NCCSA.
Payment Policy Agreement*
- I agree
You are bound by the payment policy of the NCCSA.

Submit via MAIL Instructions

If you would like to submit your payment via MAIL, fill it out the form first, DO NOT CLICK SUBMIT when you are done, and go to File > Print to print what you've filled out. You can them mail in the printout to 1775 Eye Street, NW, Suite 1150, Washington, DC 20006

Name of Program	Location of Program	Dates Attended	Degree/Certificates Awarded

Certification Application

Required Documents

Information

Current Employer

Education and Training

Previous Employment

Fees