cgfns ces application form

CGFNS Credentials Evaluation Service 2008 Edition

The CGFNS Credentials Evaluation Service (CES) is a prerequisitefor state licensure of internationally-educated registered nursesand licensed practical nurses in certain U.S. states and territories.It is also utilized by U.S. academic institutions and prospectiveemployers to assess the international education of healthcare professionals who wish to continue their education in the U.S. or want to be employed in the U.S.

The Credentials Evaluation Service results in a written reportregarding the applicant's education and professional licensure or registration credentials. Some organizations require theHealthcare Profession & Science Course-by-Course Report.Other organizations require the Full Education Course-by-Course Report. Applicants will need to designate which Report is required by the receiving organization.

CGFNS has issued more than 35,000 Credentials Evaluation Service reports for internationally-educated healthcare professionals during the past 14 years.

Applicant Handbook

A prerequisite for state licensure ofinternationally-educated:

• registered nurses• licensed practical nurses

• midwifery

in certain U.S. states and territories.

It is also utilized by U.S. academic institutions and prospective employers for the purpose of assessing the international educationof healthcare professionals

Table of Contents

Introduction to CGFNS Credentials Evaluation Service .............................................................................................................................................. 2

Choose From Two Types of Reports ...................................................................................................................................................... 2

What This Handbook Contains ................................................................................................................................................................................ 2

Chart 1: Overview of the Steps to Receive a CGFNS Credentials Evaluation Service Report ...................................................... 3

How to Apply .......................................................................................................................................................................................................... 3

How to Complete the Application ............................................................................................................................................................................ 3

Chart 2: Checklist To Prevent Common Application Form Problems ............................................................................................ 6

Preparation and Mailing of Academic Records Form ................................................................................................................................................ 6

Preparation and Mailing of Validation of Registration/License Form ........................................................................................................................ 6

Falsified or Altered Documents ................................................................................................................................................................................ 7

Changing Your Name or Address .............................................................................................................................................................................. 7

Re-Process an Application........................................................................................................................................................................................ 7

Guidelines for Communicating with CGFNS .............................................................................................................................................................. 7

World Wide Web ........................................................................................................................................................................................ 7

Authorization to Release Information Form.......................................................................................................................................... 7

Email ............................................................................................................................................................................................................ 7

Letters .......................................................................................................................................................................................................... 7

On-site Appointments .............................................................................................................................................................................. 7

Telephone Calls .......................................................................................................................................................................................... 8

In the Event of a Disaster .......................................................................................................................................................................... 8

Chart 3: Communication Guidelines ...................................................................................................................................................... 8

Request for Academic Records Form ........................................................................................................................................................................ 9

Request for Validation of Registration/License Form ................................................................................................................................................ 10

Authorization to Release Information Form ............................................................................................................................................................ 11

Credit Card Payment Form ...................................................................................................................................................................................... 12

Application Form For CGFNS Credentials Evaluation Service ...................................................................................................................................... 13

Introduction to CGFNS Credentials Evaluation ServiceThe Commission on Graduates of Foreign Nursing Schools (CGFNS International) Credentials Evaluation Service (CES) analyzesthe credentials of various types of nursing-related professionals educated and licensed outside of the United States who wish to workor study in the United States. The Credentials Evaluation Service Report helps qualified healthcare professionals demonstrate themerits of their credentials with regard to U.S. standards.

Many organizations in the United States require a credentials evaluation to help them understand educational and professionalcredentials earned outside of the country and to make appropriate assessments. Approximately one-half of the U.S. state boards ofnursing require CES Reports for foreign applicants seeking initial and endorsement licensure in their state.

The CES Report analyzes the education and licensure earned outside of the United States by nursing-related professionals andcompares this to U.S. standards. In this objective evaluation, CGFNS carefully assesses the documents received from sourceagencies. The CGFNS Credentials Evaluation Service (CES) Report is advisory in nature and does not make specific placementrecommendations. This service does not include an examination. After all required documentation, fees, and a completedapplication are received and analyzed, CGFNS prepares a report and sends it to the recipient(s) that the applicant designates. Theapplicant will also receive a copy of the report.

Choose From Two Types of ReportsCGFNS currently offers two types of CES reports. Contact the organization (the recipient) that asked to receive your CES Reportto find out which type of report is required. The two types of reports are described below:

• Healthcare Profession & Science Report – This report gives general information about the education and professionalregistration/license that you earned outside the United States. The Healthcare Profession & Science Report describes all foreigneducation and licensure in terms of similar U.S. professions and indicates the U.S. comparability. When we send your CESReport to the requested recipient(s), we will attach a copy of your healthcare academic records.

• Full Education Course-by-Course Report – This report contains the same information as the Healthcare Profession & ScienceReport but is more detailed and contains an analysis of every course from the educational program.

Both types of CES Reports contain an analysis of secondary and professional education, country-specific background informationabout schools attended by the applicant, complete dates of attendance, validations or registration/license information receiveddirectly from source authorities, and bibliographical references. All information is explained in terms of U.S. standards. CGFNS maychoose to evaluate only the materials that it considers relevant to the CES Review.

What This Handbook Contains1. Information on the Credentials Evaluation Service Program and process.2. Instructions for completing:

• The Application for Credentials Evaluation• The Request for Academic Records form, and• The Request for Validation of Registration/License form

3. Guidelines for communicating with CGFNS4. Authorization to Release information5. The Application, Request for Academic Records for Credentials Evaluation, Request for Validation of Registration/License for

Credentials Evaluation, and a form for optional payment by credit card.

The CGFNS Credentials Evaluation Service Applicant Handbook describes how to apply for and receive a Credentials EvaluationService Report. There are many steps (see Chart 1). Please read this entire booklet before completing any of the application forms.The detailed description of each step will help you to understand the complete program.

CGFNS processes all applications at its headquarters in Philadelphia, PA, USA. If you have any questions or concerns as youproceed through the CGFNS Credentials Evaluation Service, please contact the CGFNS Customer Service Department. Refer topage 7 for guidelines on communicating with CGFNS. For more information on CGFNS and its services, please visit our website atwww.cgfns.org.

2 CGFNS Credentials Evaluation Service Applicant Handbook

All steps must be completed successfully.

How to ApplyThe most convenient way for you to apply is online at www.cgfns.org. Completing the application online may speed up yourapplication process. You can download a printable version of the Application for the CGFNS Credentials Evaluation Service atwww.cgfns.org. You can also find an application form in the back of this handbook. Please follow the instructions exactly andcompletely.

How to Complete the ApplicationItem 1. A. Indicate how you learned about CES.B. Indicate why you selected CGFNS to prepare your evaluation.C. Indicate the title of your professionD. Indicate whether you have previously taken and passed the NCLEX-RN/LPN exam

Item 2. Preliminary InformationIf you have previously applied to CGFNS/ICHP for another service, fill in your CGFNS/ICHP ID number in the boxes provided.Fill in the name of the state or states where you plan to practice. Fill in the name of the country where you worked, your profession and the number of years you worked in this profession.

Item 3. Your NameList your name on the CES application form as you would like it to appear on your Credentials Evaluation Service Report.

Item 4. Other NamesPlease supply all names you have used in the past. This is necessary because CGFNS must be able to recognize all your documents,no matter what form of your name appears on them. Any variation of your name should be printed in this space. This wouldinclude your birth name as well as different spellings, informal variations, abbreviations and different orders of your name. Includewith your application any legal documentation or notarized affidavit(s) verifying your name change. For instance, if married, amarriage certificate or notarized affidavit should be attached.

Item 5. Addressesa Enter the address where you reside. b. Enter the address where you want to receive all mail from CGFNS. If you authorize someone else to receive your mailings from

CGFNS, all correspondence will go to that person’s address.If your address changes at any time during the application process, you must notify CGFNS in writing (e-mail will not be accepted);or, make changes to your contact information on the CGFNS On-Line Application System at www.cgfns.org.

CGFNS Credentials Evaluation Service Applicant Handbook 3

Chart 1: Overview of the Steps to Receive a CGFNS Credentials Evaluation Service Report

Actions You Take Actions CGFNS Takes

Identify the Report recipient and the type of report required.

Complete a CES Application Form and send it with full payment to CGFNS. CGFNS sends you an identification number.

Prepare and send the Request for Validation of Registration/License Form to your initiallicensing authority and all other licensing authorities outside of the U.S. who have issued youlicenses/registrations, asking them to send us your records.

CGFNS reviews all registrations/licenses and validates that they come from the issuingsource.

Check your status online at www.cgfns.org or through the automated phone system (215) 599-6200 using your CGFNS identification number and date of birth. Respond to anycorrespondence from CGFNS regarding missing items.

After CGFNS receives and evaluates all of the required documentation, we issue a report tothe designated recipient. We also send you, the applicant, a copy of the report.

Prepare and send the Request for Academic Records Form to any nursing or nursing-relatedpost-secondary schools that you attended outside the United States, asking them to sendyour records to CGFNS.

Send us a photocopy of your secondary school certificate/diploma.

CGFNS reviews all academic records that we receive from your healthcare or post-secondaryschools. Then we match them against our global database to find information about thespecific school and grading system.

Item 6. Current Marital StatusEnter your marital status.

Item 7. Birth DateEnter the month, day and year of your birth. The month should be spelled out and not listed as a number.

Item 8. GenderEnter whether you are male or female.

Item 9. CitizenshipPlease list your country of birth and country of current citizenship. Please provide a citizenship identification number oridentification number from country of birth, if applicable. Also list your native language and the country in which you received yourinitial professional education.

Item 10. Your Telephone Number, Mobile (cell phone) Number, Fax Number and E-mail AddressPlease enter contact information where you can be reached. Please answer the questions regarding cell phone and text messagingcontact by CGFNS.

Item 11. U.S. Social Security NumberThe U.S. Social Security Number is an identification number issued by the U.S. Government. Please enter this number, if known.

Item 12. Education

Please list all primary, secondary, professional nursing related and professional non-nursing related educational institutions that youattended, the countries in which the schools were located, and dates of attendance (month/year). Include all schools, whether youcompleted the program of study or not, beginning with your primary school then secondary school and professional healthcareschool. Check whether or not your education resulted in a degree. Explain any gaps in your educational history.Send a copy of the “Request for Academic Records Form” to each school listed. CGFNS can only accept the transcript from theauthorized issuing body.

Secondary School Diploma

Include a clear copy of your secondary school credential. Examples of this would be: a secondary school diploma, results of anexternal exam, or General Education Development (GED) certificate.

• Diploma Not in English

If your diploma or certificate is not in English, you must attach a literal English translation, not a summary. The followingsentence, referred to as a “Certificate of Accuracy,” must be typed or written at the end of the translation and must be signed bythe translator. It does not need to be notarized. Transcripts from secondary schools do not need to be translated by an officialtranslator.

• Unable to Obtain a Copy of Your Diploma

If you cannot obtain a copy of your diploma, you may request that your secondary school send a letter directly to CGFNS,confirming your dates of attendance and date of graduation. If you cannot obtain a copy of your certificate that was awardedbased on the results of an external exam (for example, GCE, GCSE, Irish Leaving Certificate, WAEC), you may ask the examiningboard to send a letter directly to CGFNS certifying the grade(s) earned on the examination(s).

Letters submitted by a secondary school or examining board must be written on official stationery; be signed by a schoolprincipal; headmaster or an examining board official; and, contain the school’s or examining board’s stamp or seal. If the letter isnot in English, include a literal translation with a Certificate of Accuracy signed by the translator.


Example of Certificate Of Accuracy“This is to certify that this is a true and correct English translation of the attached photocopy of the original [name of document] of [applicant’s name].”

• Form V

Applicants educated in countries where completion of “Form V” is considered completion of secondary school, may submit oneof the following documents as verification:• statement of completion of “Form V” issued by the headmaster or school principal• official secondary school transcript showing completion of “Form V,” or• external examination results

Item 13. Registration/Licensea. Check the appropriate box if you are not currently registered/licensed and explain.

b. Please list your legal professional title(s) and country(ies) where your title(s) are registered/licensed.

c. List the state(s)/province(s)/country(ies) where you hold a current registration/license as a healthcare professional.d. Indicate whether your registration/license has ever been revoked, suspended or restricted. Be sure to answer this question for all

registration/licenses that you hold now and have held in the past.Failure to answer the questions in Item 13 will result in a delay in evaluating your application.

Items 14a, 14b, 14c, 14d, 14e, 14f. Report Recipients

List the names and addresses of one or two recipients for your CES Report. This would include a state board of nursing, aneducational institution, or a potential employer. For each recipient, indicate the type of report and purpose of the request. Youautomatically receive a copy of the report. It is not necessary to list yourself. Please note the CES report is used by U.S. institutions.If you are selecting an international recipient please provide a written explanation.

Item 15. Application FeeThe Application fee can be paid by:

• Credit card — CGFNS accepts Visa, MasterCard and Discover/Novus (CGFNS does not accept American Express). • International money orders or certified bank checks made payable to “CGFNS.”

Personal checks are not accepted.

All fees must be paid in U.S. dollars drawn on a U.S. bank.

Before your file can be reviewed, we must receive the full application fee as determined by the number of items entered in thissection. Note that any money submitted to CGFNS/ICHP will first be applied to any unpaid balance from previously orderedproducts or services before new orders are processed.

The fees cover the expense of processing your application, reviewing your credentials, preparing the CES Report and postage.

Applications remain open for 12 months. Applicants who do not meet the requirements of the CES program within the first 12months of their order may continue the service by applying for Re-Process and paying the associated fee.

Item 16. Terms and Conditions of the CES ApplicationThis is a summary of the responsibilities of the applicant and CGFNS.

Item 17. Attestation

The attestation in Item 17 creates a contract between you and CGFNS. It explains the terms under which CGFNS will process yourapplication. After reading it carefully, sign and date the form. By signing the form, you certify that no portion of the documentssubmitted to CGFNS on your behalf is falsified, altered or tampered with by any person. CGFNS and others will rely on thisapplication and on the documents and information submitted. If any portion of the application or documents submitted is falsified,altered or tampered with, or if you alter a CGFNS Credentials Evaluation Service Report or misrepresent a copy as an original,CGFNS may take any disciplinary action against you that it deems appropriate, including barring you from future participation inany CGFNS programs. The consequences could adversely affect your professional license, immigration status, employment andother matters.

Signature

Sign the Application Form with the same name you indicated in Item 3 of the application. You will be required to use the samesignature each time you correspond with CGFNS or when CGFNS asks for your signature. The resulting CGFNS CredentialsEvaluation Report will be issued using the name provided on your application. The Application Form does not need to be notarized.


If You Choose to Mail Your ApplicationAfter completing your Application Form, send it to CGFNS, along with a photocopy of your secondary school diploma, and allrequired fees. Send your application materials to the following address:

CGFNSAttn: CES Application3600 Market Street, Suite 400Philadelphia, PA 19104-2651 USA

CGFNS does not return any of the documents that are part of your complete application.

Remember to send readable photocopies, not originals, of the documents CGFNS requests directly from you. Applicationsremain open for one year (12 months).

Preparation and Mailing of Academic Records FormTo give CGFNS the necessary information about your education, you will need to send one copy of the Request for AcademicRecords form to each healthcare or post-secondary school that you attended outside the United States to ask them to send us youracademic records. Provide all of the requested information on the front (the applicant's side) of the form before sending the form toeach school that you attended. Enclose any payment that your school(s) may require (including translation costs).

IMPORTANT: We must receive all of your nursing-related academic records directly from your school(s). We cannot acceptrecords supplied by you or anyone else other than the school. If we receive foreign-language documents without an Englishtranslation, we can have them translated for the fee stated on the fee schedule, at your request.

Preparation and Mailing of Validation of Registration/License FormYou must request validations for your current and initial registrations/licenses obtained outside the U.S. To do this, use the Requestfor Validation of Registration/License for Credentials Evaluation Service form included in this applicant handbook. If you need tovalidate more than one registration or license credential, make photocopies of the blank form. Complete the front of the form (theapplicant's side) and mail it to the authority that issued your registration or license. The section titled “For Registration AuthorityUse Only” is to be completed by your licensing agency. If you have a diploma that authorized you to practice in your country, sendthis form to the institution that issued your diploma (for example, your school or the Ministry of Health) and request that an officialcopy of the diploma in the original language be sent to CGFNS. Further information may be required after your file is initiallyreviewed.

Additional Requirements for New Jersey and MichiganThe New Jersey Board of nursing requires proof that the applicant has achieved a passing score on the English ProficiencyExamination required by the Department of Homeland Security for certification of healthcare workers in Section 343 of the IllegalImmigration Reform Immigrant Responsibility Act of 1996. The Michigan Board of Nursing also requires proof of EnglishLanguage Proficiency for applicants who graduated from a nursing school program that was taught in a language other thanEnglish. The CGFNS CES Report must be accompanied by this English language Proficiency Report containing the passing scoresof the approved English examinations detailed in the CGFNS VisaScreen® handbook.


Chart 2: Checklist To Prevent Common Application Form ProblemsCheck Each Item Below to Ensure that You Avoid Common Application Problems

Before mailing your application, check to see that you have:□ entered a response to every item□ included, in Item 4, every form of your name that appears on your application documents and any necessary proof of your other names□ completed the enclosed Request for Academic Records Forms and sent them to the appropriate education institutions (see page 6)□ completed the enclosed Request for Validation of Registration/License Forms and sent them to the appropriate licensing authorities (see page 6)□ every document is either in English or has a literal English translation attached that includes a Certificate of Accuracy, signed by the translator (see page 4)□ signed the application□ included credit card payment, international money order or certified bank check for the full application fee in U.S. dollars, drawn on a U.S. bank, payable to

“CGFNS.” DO NOT SEND CASH.

Falsified or Altered DocumentsIf CGFNS finds that your documents have been altered in any way or that information in your application is false, whethersubmitted by you or on your behalf by another person, CGFNS will not issue a Credentials Evaluation Service Report on yourbehalf. Therefore, before anything is sent to CGFNS make certain that none of the material has been falsified or altered in any way.Submitting falsified or altered documents will result in your file being closed, loss of your entire application fee and ineligibility forfuture CGFNS/ICHP services.

Changing Your Name or AddressIf you have changed your legal name, CGFNS can make the change in your application file when we receive your signed, writtenrequest with legal proof of name change. Requests to change your mailing address must be in writing or you may make the changeonline through the CGFNS website. In your letter requesting any of these changes, remember to include your CGFNS ID Numberand birth date. E-mail requests for change of name and address will not be accepted at any time.

Re-Process an ApplicationApplicants applying for the Credentials Evaluation Service will be given 12 months to meet the requirements of the program. Ordersfor the Credentials Evaluation Service that have not resulted in the issuing of a Credentials Evaluation Service report within 12months of the application date will be expired. Once an order is expired, an applicant can re-apply with a re-process application andpay a second year re-process an expired order fee. Re-process orders remain open for 12 months starting from the date the re-processorder is placed. A re-process order cannot be placed until the previous order is expired.

Guidelines for Communicating with CGFNSIf you have questions about your application or required documents, we recommend that you first go to the CGFNS website,www.cgfns.org to check the status of your account, or you may access your account through our Automated Phone System (215) 599-6200. You may also contact CGFNS via letter, telephone, or through our website at www.cgfns.org “Contact us”. We offer thefollowing guidelines to make this communication easier (see Chart 3 on page 8 for additional information).

World Wide WebYou may access the CGFNS website for information on CGFNS and its programs, services and activities, application forms, and theOn-line Application System at www.cgfns.org. To login and check your status, you must create a username and password.

Authorization to Release Information FormIf you want someone else to be able to access information from your confidential files, you must complete an Authorization toRelease Information form and return the completed form to CGFNS. We will not release information to anyone other than theapplicant without an Authorization form. You can revoke this authorization in writing at any time by sending CGFNS a signed letterstating that you revoke the Authorization. Authorization to Release Information forms are available on CGFNS’s website atwww.cgfns.org or on page 11 of this Handbook.

E-mailApplicants may contact the CGFNS Customer Service Department with questions regarding their application by e-mail atwww.cgfns.org “Contact us”.

LettersCGFNS treats your application as confidential, to be discussed only with you unless you have named an authorized agent. Whenyou send a letter, it must be written and signed only by you. When you write to us, always include your CGFNS ID Number, fullname, and birth date. CGFNS recommends that you send all correspondence by first-class mail, and that you consider other fastermailing options when time is limited.

On-site AppointmentsAn applicant or authorized agent may make an appointment to discuss the applicant’s file by scheduling a 30-minute appointmentin our CGFNS office in Philadelphia, PA. Appointments are available Monday through Friday between 100:00 a.m. - 3:30 p.m.(Eastern Standard Time in the United States) and may be made by calling the office at 215-222-8454


Telephone CallsThe CGFNS Customer Service Department provides applicant status information by telephone to applicants only. CGFNS will notrelease information by phone to anyone else unless a completed and signed “Authorization to Release Information” form has beenreceived from the applicant. If you wish to telephone, call our Customer Service Department at (215) 349-8767. To save time, haveyour CGFNS ID Number ready.

If the Customer Service Representative is unable to adequately verify your identity, information will not be released by telephone.

Phone lines are generally open Monday through Thursday between 9:00 a.m. and 5:00 p.m. (Eastern Standard Time in the UnitedStates), and 9:00 a.m. and 4:30 p.m. on Friday. The phone lines are not open evenings, weekends or on U.S. holidays. In an effort tokeep our costs to you at a minimum, CGFNS will not accept collect telephone calls.

CGFNS also has an Automated Voice Response telephone system that is available 24 hours a day, 7 days a week. By inputting theiridentification number and date of birth, applicants can verify receipt of documentation and examination scores, confirm file status,and access other information. Applicants can reach this system at (215) 599-6200.

In the Event of a DisasterCGFNS makes every effort to ensure that our communication with applicants is clear and timely. However, some events are out ofour control. Events such as natural disasters, political unrest and postal strikes may occasionally affect the application process.CGFNS cannot be responsible for delays caused by such conditions, but we will make every reasonable effort to notify you of anyalternate arrangements.


Chart 3: Communication Guidelines

Reasons for Communication Who Can Initiate Request? Communication Channel Special Tips

You wish to obtain copies of the CGFNSCredentials Evaluation Applicant Handbook.

Anyone. E-mail through our website www.cgfns.org“Contact Us” , write, telephone or downloadfrom the web site.

An individual can receive 1 CES handbook freeof charge by mail. If ordering additionalcopies, the fee (and any shipping costs) mustbe pre-paid.

You want to confirm whether CGFNS receivedyour application documents.

Only you or your authorized agent. E-mail through our website www.cgfns.org“Contact Us”, write, telephone, or visit the On-line Application System (CGFNS Connect)at www.cgfns.org.

Include your Full Name, CGFNS/ICHPID number and date of birth.

You have a question about a letter that youreceived from CGFNS/ICHP.

Only you or your authorized agent. E-mail through our website www.cgfns.org“Contact Us” , write or telephone.


You need to notify CGFNS of a change ofaddress.

Only you or your authorized agent. E-mail through our website www.cgfns.org“Contact Us”, write, or make changes online atwww.cgfns.org via the On-Line ApplicationSystem (CGFNS Connect).


Legal name change Only you Write to CGFNS including legal documenationof name change

Request should include signature, full name,CGFNS/ICHP ID number ID number and dateof birth.

Dear Registrar:

Please promptly complete the lower part of this form and send it to the Commission on Graduates of Foreign Nursing Schools (CGFNS International)along with my academic record(s) listing the courses taken, hours of study, clinical practice hours and grades earned, accompanied by a certified Englishtranslation.

My current name is: (Print or type your current name)

I attended (name of school) _________________________________ between (dates of attendance) ________/_______ and _________/______

My birth date is: Month (spell out) ______________________________ Day _________ Year _________

The name I used when I attended your school was: (Print or type the names you used when attending this school)

My CGFNS ID# (if known) is:

My Order# (if known) is: ___________________ Applicant Signature ____________________________________________

My current address is:

Telephone Number Fax Number E-mail Address

Request For Academic Records For Credentials Evaluation Service

Address

Address – Continued

City

Country

First Name Middle Name Last Name


Month / Year Month / Year

Subjects Hours of Theoretical Instruction* Hours of Clinical Practice

Care of the Adult — Medical NursingCare of the Adult — Surgical NursingMaternal/Infant Nursing, excluding GynecologyNursing Care of ChildrenPsychiatric/Mental Health Nursing, excluding Neurology

Gerontology NursingPharmacologyPhysiologyPsychologySociology Anatomy

Nutrition

* Includes hours of classroom education, laboratory, and planned clinical conferences (ward teaching)

School Seal orStamp MustCover Signature

Credentials Evaluation ServiceCGFNS3600 Market Street, Suite 400Philadelphia, PA 19104-2651, USA

Sign and Print entire name, title and date

Please place school seal or stamp overflap of envelope after sealing and returnthe transcript/academic record(s) ALONGWITH THIS FORM via airmail to: è

Signature _________________________________________________________________

FOR NURSES ONLY: In addition to a copy of the transcript, please provide specific hours of theoretical instruction and hours of clinical practice for the subject areas listed below. Please do not combine subject areas. If they are combined in your curriculum, please estimate the hoursof theoretical instruction and hours of clinical practice in each subject area. All documents must be in English.

FOR SCHOOL USE ONLY: What is the applicant’s birthday? Mo._________ Day ______ Yr_____ Admission or start date of program Mo.__________ Day _____ Yr______

What was the language of instruction for this applicant?____________________

What was the textbook language for the applicant’s program/course of study? _____________________________

Type of program (i.e. diploma, baccalaureate, midwifery) __________________________

Is your school a government-approved school? M Yes M No

I hereby attest that the enclosed Academic Recordaccurately states courses taken, hours of study, and grades received for the above-named individual.

Date of program completion Mo._________ Day _____ Yr______

State/Province Postal/Zip Code

(Applicants to complete this side)

FOR REGISTRATION AUTHORITY USE ONLY:

1. This is to certify that ________________________________________________________ was first issued registration/license/diploma

number ____________ to practice as a ___________________________________________________ on: ______/_______/_______.

The expiration date of this registration/license is: ______/_______/_______. Birth date of individual: ______/_______/_______

2. Authority to Practice:

M National/Provincial/State Examination

M Review of another license (endorsement)

M Registration M Diploma

M Other: __________________________

4. Name and location of professional education program completed: ______________________________________________________

5. Date of graduation: ______/_______/_______

6. Professional education program accredited/government approved? M Yes M No By Whom? ________________________________

7. Type of Program: M Diploma M Baccalaureate DegreeM Associate Degree M Other (specify) ___________________________________

8. Signature of registration authority Date: _______/_______/_______(Do not print) Sign and Print entire name

Registration authority title: ____________________________________

State/Province and Country: _______________________________________

Month Day Year

Month Day Year

Month Day Year

Month Day Year

Month Day Year

(Specify legal title)

(Applicant Name)

Please send this document and anyattachments in English, in theenclosed envelope. Sign your nameover the flap after sealing. Send viaairmail to:è

3. Status

M Active/Current M Expired

M Inactive M Restricted*

*Please attach an explanation ifthe applicant’s registration/license/diploma has ever beenrevoked, suspended, limited, orplaced on probation.

RegistrationAuthoritySeal or StampMust CoverSignature

Credentials Evaluation ServiceCGFNS3600 Market Street, Suite 400Philadelphia, PA 19104-2651, USA

Dear Registration Authority:

Please promptly complete the other side of this form and send it to the Commission on Graduates of Foreign Nursing Schools (CGFNS International)as validation of my professional registration/license, accompanied by a certified English translation.

My current name is:

My registration/license number is ______________________ My birth date is: Month __________________ Day ______ Year _______

The registration/license was issued under the name of:

My CGFNS ID# (if known) is:

My Order# (if known) is: ___________________ Applicant Signature ____________________________________________

My current address is:

Country

Address

Address – Continued

City




Telephone Number Fax Number E-Mail Address

(Required for all Applicants)

Request forValidation of Registration/License For Credentials Evaluation Service

AUTHORIZATION TO RELEASE INFORMATION

NOTICE: By signing below you: (1) allow CGFNS/ICHP to disclose confidential, personal, private information about you and yourfile at CGFNS/ICHP to the person designated below; (2) give up the right to receive information from CGFNS/ICHP directly; and(3) release and indemnify CGFNS/ICHP, its members, trustees, officers and employees from any liability for losses, damages or claimsof any type arising out of actions taken by CGFNS/ICHP in reliance upon this Authorization.

This Authorization will remain valid for two years from the date written below (or if none, from the date this Authorization is received byCGFNS/ICHP).

REVOCATION: This Authorization can be revoked by submitting a new Authorization dated and signed after the initial Authorization.

In addition, you may revoke this Authorization in writing at any time, which will be effective within 30 days from the day thatCGFNS/ICHP receives your written revocation by regular mail or courier at its headquarters office in Philadelphia, PA, USA.

AUTHORIZATION: I authorize CGFNS/ICHP to release to the below-named Authorized Agent any and all information about me andmy application/order for services from CGFNS/ICHP, including without limitation, the status of my application/order, the results of anycredentials review, examination or test, and any other information in or relating to my file at CGFNS/ICHP. I understand that all mail(including Certificate, exam scores and reports) will be sent to the Authorized Agent.

This Authorization revokes all previous Authorizations submitted by the applicant.

CGFNS/ICHP ID No.___________________ (if known)

Date of Birth: _________________________ (M/D/YR)

Sign name as it appears on your Application/Order:__________________________________

Print name: ________________________________________

Date: ____________________________ (M/D/YR)

AUTHORIZED AGENT:Note: This form is not for report recipients. Report recipients, for example, State Boards of Nursing, are listed in Section 14 of the application.

Print Contact Name: __________________________________________________________

Print Organization Name: ______________________________________________________

Print Address: ______________________________________________________

______________________________________________________

______________________________________________________

Telephone: Day: ___________________________ Fax number: ______________________

Evening: ________________________ E-mail: __________________________

3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 U.S.A.Phone: 215.222.8454 • Web: www.cgfns.org

Credit Card Type (check one): CGFNS does not accept American Express

� Visa � MasterCard � Discover/Novus

Name of Cardholder (as it appears on card):

Cardholder Address: (For processing credit card payments only. Allmaterials requested will be sent to the applicant address provided on the appropriate forms.)

Credit Card #:

Expiration Date: *CVV2 Number

Total Charges (see “Fee Schedule”): U.S. $

Cardholder Signature (authorization for payment):I hereby authorize a charge to my credit card for the total of allservices requested on the attached Certification ProgramApplication Form, including any fee adjustments in effect as ofthe date the order is received.

X

(See explanation on other side.)

Signature of Authorized Cardholder


Credit Card Payment Form:To pay by credit card, please fill in your full name (as it appears on this application) and your CGFNS/ICHP Applicant ID Number (if known)below. Complete the cardholder information requested on the other side. Detach this form only if payment is being made by a third party.

Name of Applicant:

CGFNS/ICHP Applicant Identification Number (if known)

Applicant’s Date of Birth:

Day Month Year

*Explanation of Credit Card CVV2 Number: ( To be entered below)Visa and MasterCard: This number is printed on yourMasterCard & Visa cards in the signature area of the card. (It is the last 3 digits AFTER thecredit card number in the signature area of the card).

If you already have a CGFNS/ICHP Identification Number, enter it here. Order # (if known) __________

A. Intended U.S. State(s) of practice _____________________________ .

B. I worked in ________________________________ as a __________________________________ for _______ years.City/Country Profession Specialty Number

Please assist us by answering two brief questions. Your cooperation will aid us in serving you better in the future.

A. How did you learn of CGFNS/ICHP’s Credentials Evaluation Service?

□ U.S. College/University □ State Licensure Board □ Recruiter □ U.S. Employer □ Immigration Attorney □ CGFNS mailed you information □ Other (Please explain) ___________________________________________________

B. Why did you select CGFNS/ICHP over another organization for your Credentials Evaluation Services?

□ Instructed by your report recipients □ We sent you (or you requested) an application □ Price □ CGFNS’ reputation □ Other (Please explain)___________________________________________________________________________________

C. Title of your profession _____________________________________________________________________________________

D. Have you previously taken and passed the NCLEX-RN®or LPN exam? M Yes M No

Country of Birth ____________________________________ State/Province _____________________________

Citizenship ID Number_________________________ Native Language _________________________________

Current Citizenship __________________ Country of Initial Professional Education____________________

First and Middle Names (Leave a space between names)

Last (Family) Name (Leave a space between names)

Name Before Marriage

Other Names (for married women only)

Street Address/ Post Office Box Number

Address - Continued

City

Postal/Zip Code Country

□ Single (Never Married) □ Married

□ Divorced □ Widowed

Enter your full, legal name as you would like it to appear on the report. Print or type only one letter in each box.

Enter alternate names appearing in your documents. Include legal documentation verifying each name change (for example: marriage certificate).

Indicate the address where you reside.

Day Year

Month

State/Province

1 Our Commitmentto Service

2 PreliminaryInformation

3 Your Name

4 Your Other Names(if applicable)

5a PermanentAddress

6 CurrentMarital Status

7 Your Birth DateSpell the month, enterday and year of birth.

8 Gender □ Female□ Male

9 Citizenship

Street Address/ Post Office Box Number

Address - Continued

City

Postal/Zip Code Country

Provide the address where you want to receive your mail.

State/Province

5b Mailing Address

CGFNS International • 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 U.S.A. • Phone: 215.222.8454 • Web: www.cgfns.org

Credentials Evaluation Service

2008 Application (Required for all applicants)

Please provide the following information.

A. If you are not currently registered/licensed, please indicate and explain. □ Not currently registered/licensed □ Never registered/licensed

Explanation: _____________________________________________________________________________________________

________________________________________________________________________________________________________

B. List your legal professional title(s) and country(ies) where you are currently licensed or have held a license.

________________________________________________________________________________________________________

C. List the state(s)/province(s)/country(ies) where you have ever held registration/license as a healthcare professional.

_________________________________________________________________________________________________________

D. Have any of your registrations/licenses ever been revoked, suspended or restricted for any reason? □ Yes □ No If “Yes”, please attach an explanation to your application.

Name of Non-healthcare Schools Attended City & Country Month/YearEntered

Month/YearCompleted/Graduated

Name of Diploma orCertificate in its

Original Language

Please list, in the order you attended them, all professional healthcare educational institutions. Explain any gaps in youreducational history.

Indicate here the names and addresses of as many as two different recipients for your report. For each recipient, indicate the typeof report and purpose of the request. NOTE: It is not necessary to list yourself; you automatically receive a copy of the report.

Name andAddress of the First Recipient of Your Report

Address/Post Office Box Number

Address - Continued

City


Country

Name of Organization

Name of Contact Person or Title

Pre-healthcare ProfessionEducationList information for eachschool attended whethercompleted or not. Enclose aphotocopy of your diploma,certificate, or external examcertificate from yoursecondary school, includingword-for-word English translations of each of thesedocuments. External examresults or school verification ofgraduation date must besubmitted directly to CGFNS/ICHP by the examiningagency or school.

Healthcare EducationList information for eachschool attended whethercompleted or not. Forward acopy of “Request forAcademic Records Form” toeach school listed here.

Primary:

Intermediate

Secondary:

Post-secondary non-professional programs:

Phone: Include Country Code/Area Code E-Mail Address (example: [email protected])

( )

–– ––

FAX: Include Country Code/Area Code

( )

Mobile (cell) : Include Country Code/Area Code

( )

12 Institutions Attended

DegreeObtained

( uu )

Name of Professional Healthcare Schools Attended

City, State/Province,Country

Month/YearEntered

Month/YearCompleted/Graduated

Name of Diploma orCertificate in its

Original Language

DegreeObtained

( uu )

TitleObtained

14a ReportRecipients

13 Registration/LicenseForward a copy of “Request forValidation of Registration/License Form” to the authoritywhere you were initiallyregistered/licensed and to allauthority(ies) where you arecurrently registered/licensedoutside of the U.S.

10 Your Telephone,Mobile (cell phone),& FAX Numbersand E-mail Address(if available)

May CGFNS send you a text message on your mobile (cell) phone? M Yes M No

What is your preferred method of communication from CGFNS? M Mail M Email

11 Your U.S. SocialSecurity Number

Fill in your Social SecurityNumber (if you have one)

Please list, in the order you attended them, all non-healthcare educational institutions, beginning with the first year of yourprimary school education and ending with the last year of non-healthcare education. Explain any gaps in your educationalhistory. (Please fill in all spaces in the charts below completely or your application will be returned to you.) If your school hasclosed or merged, provide the name and address, if known, where your records are located.

Has your nursing school closed or merged with another school? □ Yes □ No If Yes, Name of School ______________________

Ed. 3–2/08 ©2008 CGFNS. All rights reserved.

First Recipient (continued)

□ RN Licensure □ LPN Licensure □ Academic Admission□ Employment □ Immigration □ Certification □ Other ________________________

□ RN Licensure □ LPN Licensure □ Licensure Endorsement □ Academic Admission □ Employment □ Immigration □ Certification □ Other ________________________

□ Healthcare Profession & Science Report □ Full Education Course-By-Course Report

Select only one type of report. If you are requesting that two different types of reports be issued to two recipients, you should pay forthe most detailed report requested. Please confirm the type of report needed with your recipient(s).

Check □ here to indicate selection. Refer to Fee insert for current year. □ Healthcare Profession & Science Report.....................................................................$_______□ Full Education Course-By-Course Report ...................................................................$_______□ CGFNS Language Report: English .................................................................................$_______□ Other CES Services (refer to fee schedule).................................................................$_______ $___________

Use This Column to Compute Total Fees Due3

Refer to page 1 of Application Handbook for an explanation of both CES Reports.

□ Healthcare Profession & Science Report □ Full Education Course-By-Course Report

Full payment for all services requested must be included with your application. Send only a certified bank check or internationalmoney order, drawn in U.S. dollars on a U.S. bank, and made payable to “CGFNS,” or pay by credit card using the Credit CardPayment Form, or pay on-line at www.cgfns.org. Personal checks are not accepted.

= $___________

14b Type of Report

14c Purpose of This Report

Indicate here the name and address of the Second recipient for your report. Indicate the type of report and purpose of the request.

Address/Post Office Box Number

Address - Continued

City


Country

Name of Organization

Name of Contact Person or Title

14d Name & Addressof the SecondRecipient of YourReport(if applicable)

14e Type of Report

14f Purpose ofThis Report

15a Credentials Evaluation Report Fees

15b TotalApplication Fee

The following clarifies the obligations of the provider (CGFNS/ICHP) and applicant (you) of the Credentials EvaluationService, as well as the manner in which this service is delivered.

• CGFNS may choose to evaluate only the materials that it considers relevant to the CES Review.• All documents submitted, including transcripts, become the property of CGFNS and cannot be returned to you. Do not

send originals of diplomas, degrees, certificates, registrations or licenses.• If your application includes any forged, altered or falsified documents or information, CGFNS will not prepare an

evaluation report and no refund will be issued.• No evaluation is performed until CGFNS receives full payment. Please calculate the payment correctly and include it

with each application or request. See Fee Schedule.• The CES Report is valid only when the official (embossed) CGFNS seal is affixed.• State Boards of Nursing access CES reports online. All CES Reports to applicants and to non-State Board

of Nursing recipients are sent via First Class mail (within the U.S.) or airmail (outside of the U.S.).• Fees as published with this application may change without notice.• Any payment sent to CGFNS will be applied first to any unpaid balance from a previous order for product or services

before it is applied as payment for a newer order.• No refund is given after an application is submitted.• Applications remain open for 12 months. Applicants who do not meet the requirements of the CES program

within the first 12 months of their order may continue the service by applying for Re-Process and paying the associated fee.

16 Terms andConditions of the CES


I agree to the Terms and Conditions of the Credentials Evaluation Service outlined in Item 16.I certify that all information that CGFNS has received as a part of this application now or in the past from me or

from a third party on my behalf, is true and complete. I also certify that all documents which have been submittedto CGFNS for any purpose have not been falsified, altered or tampered with by any person.

I understand that CGFNS and others will rely on this application and on the documents and informationsubmitted, and that if any of the items are falsified, altered or tampered with, or if I alter a CGFNS Certificate or aCGFNS Report or misrepresent a copy as an original, CGFNS may take such disciplinary action against me as it deemsappropriate, and the consequences could adversely affect my professional license, immigration status, employmentand other matters, from which I release CGFNS from all liability.

I authorize CGFNS to disclose the information and documents in this application, the status of my CGFNSCertificate, any reports or evaluations prepared by CGFNS, any other information obtained by CGFNS, and the resultsand reasons for any adverse action taken against me by CGFNS, to any person or organization I designate in writingor to any other recipient which CGFNS may determine has a legitimate interest in receiving the same, such asgovernment agencies and potential employers.

You must sign and date this application in order for it to be processed.

Signature of Applicant (Do Not Print)Sign Entire Name

Date

17 Attestation




CGFNS MissionProvide expert credentials evaluation and professional development

services to promote the health and safety of the public.