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7181415 CGFNS CES Application Form
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The CGFNS Credentials Evaluation Service (CES) is a prerequisite for state licensure of internationally-educated registered nurses and licensed practical nurses in certain U.S. states and territories. It is also utilized by U.S. academic institutions and prospective employers 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 report regarding the applicant's education and professional licensure or registration credentials. Some organizations require the Healthcare Profession & Science Course-by-Course Report. Other organizations require the Full Education Course-byCourse 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.
A prerequisite for state licensure of internationally-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 education of healthcare professionals
Introduction to CGFNS Credentials Evaluation Service .............................................................................................................................................. Choose From Two Types of Reports ...................................................................................................................................................... What This Handbook Contains ................................................................................................................................................................................ Chart 1: Overview of the Steps to Receive a CGFNS Credentials Evaluation Service Report ...................................................... How to Apply .......................................................................................................................................................................................................... How to Complete the Application ............................................................................................................................................................................ Chart 2: Checklist To Prevent Common Application Form Problems ............................................................................................ Preparation and Mailing of Academic Records Form ................................................................................................................................................ Preparation and Mailing of Validation of Registration/License Form ........................................................................................................................ Falsified or Altered Documents ................................................................................................................................................................................ Changing Your Name or Address .............................................................................................................................................................................. Re-Process an Application........................................................................................................................................................................................ Guidelines for Communicating with CGFNS .............................................................................................................................................................. World Wide Web ........................................................................................................................................................................................ Authorization to Release Information Form .......................................................................................................................................... Email ............................................................................................................................................................................................................ Letters .......................................................................................................................................................................................................... On-site Appointments .............................................................................................................................................................................. Telephone Calls .......................................................................................................................................................................................... In the Event of a Disaster .......................................................................................................................................................................... Chart 3: Communication Guidelines ...................................................................................................................................................... Request for Academic Records Form ........................................................................................................................................................................ Request for Validation of Registration/License Form ................................................................................................................................................ Authorization to Release Information Form ............................................................................................................................................................ Credit Card Payment Form ...................................................................................................................................................................................... Application Form For CGFNS Credentials Evaluation Service ...................................................................................................................................... 2 2 2 3 3 3 6 6 6 7 7 7 7 7 7 7 7 7 8 8 8 9 10 11 12 13
Introduction to CGFNS Credentials Evaluation Service
The Commission on Graduates of Foreign Nursing Schools (CGFNS International) Credentials Evaluation Service (CES) analyzes the credentials of various types of nursing-related professionals educated and licensed outside of the United States who wish to work or study in the United States. The Credentials Evaluation Service Report helps qualified healthcare professionals demonstrate the merits 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 professional credentials earned outside of the country and to make appropriate assessments. Approximately one-half of the U.S. state boards of nursing 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 and compares this to U.S. standards. In this objective evaluation, CGFNS carefully assesses the documents received from source agencies. The CGFNS Credentials Evaluation Service (CES) Report is advisory in nature and does not make specific placement recommendations. This service does not include an examination. After all required documentation, fees, and a completed application are received and analyzed, CGFNS prepares a report and sends it to the recipient(s) that the applicant designates. The applicant will also receive a copy of the report.
Choose From Two Types of Reports
CGFNS currently offers two types of CES reports. Contact the organization (the recipient) that asked to receive your CES Report to 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 professional
registration/license that you earned outside the United States. The Healthcare Profession & Science Report describes all foreign education and licensure in terms of similar U.S. professions and indicates the U.S. comparability. When we send your CES Report 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 & Science
Report 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 information about schools attended by the applicant, complete dates of attendance, validations or registration/license information received directly from source authorities, and bibliographical references. All information is explained in terms of U.S. standards. CGFNS may choose to evaluate only the materials that it considers relevant to the CES Review.
What This Handbook Contains
1. 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 CGFNS 4. Authorization to Release information 5. 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 Evaluation Service 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 you proceed through the CGFNS Credentials Evaluation Service, please contact the CGFNS Customer Service Department. Refer to page 7 for guidelines on communicating with CGFNS. For more information on CGFNS and its services, please visit our website at www.cgfns.org.
2 CGFNS Credentials Evaluation Service Applicant Handbook
Chart 1: Overview of the Steps to Receive a CGFNS Credentials Evaluation Service Report
Identify the Report recipient and the type of report required. Complete a CES Application Form and send it with full payment to CGFNS. Prepare and send the Request for Academic Records Form to any nursing or nursing-related post-secondary schools that you attended outside the United States, asking them to send your records to CGFNS. Send us a photocopy of your secondary school certificate/diploma. Prepare and send the Request for Validation of Registration/License Form to your initial licensing authority and all other licensing authorities outside of the U.S. who have issued you licenses/registrations, asking them to send us your records. 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 any correspondence from CGFNS regarding missing items. CGFNS reviews all registrations/licenses and validates that they come from the issuing source. After CGFNS receives and evaluates all of the required documentation, we issue a report to the designated recipient. We also send you, the applicant, a copy of the report. CGFNS sends you an identification number. CGFNS reviews all academic records that we receive from your healthcare or post-secondary schools. Then we match them against our global database to find information about the specific school and grading system.
Actions CGFNS Takes
All steps must be completed successfully.
The most convenient way for you to apply is online at www.cgfns.org. Completing the application online may speed up your application process. You can download a printable version of the Application for the CGFNS Credentials Evaluation Service at www.cgfns.org. You can also find an application form in the back of this handbook. Please follow the instructions exactly and completely.
A. Indicate how you learned about CES. B. Indicate why you selected CGFNS to prepare your evaluation. C. Indicate the title of your profession D. Indicate whether you have previously taken and passed the NCLEX-RN/LPN exam
Item 2. Preliminary Information
If 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 Name
List your name on the CES application form as you would like it to appear on your Credentials Evaluation Service Report.
Item 4. Other Names
Please 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 would include your birth name as well as different spellings, informal variations, abbreviations and different orders of your name. Include with your application any legal documentation or notarized affidavit(s) verifying your name change. For instance, if married, a marriage certificate or notarized affidavit should be attached.
Item 5. Addresses
a 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
Item 6. Current Marital Status
Enter your marital status.
Item 7. Birth Date
Enter the month, day and year of your birth. The month should be spelled out and not listed as a number.
Item 8. Gender
Enter whether you are male or female.
Item 9. Citizenship
Please list your country of birth and country of current citizenship. Please provide a citizenship identification number or identification number from country of birth, if applicable. Also list your native language and the country in which you received your initial professional education.
Item 10. Your Telephone Number, Mobile (cell phone) Number, Fax Number and E-mail Address
Please enter contact information where you can be reached. Please answer the questions regarding cell phone and text messaging contact by CGFNS.
Item 11. U.S. Social Security Number
The 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 you attended, the countries in which the schools were located, and dates of attendance (month/year). Include all schools, whether you completed the program of study or not, beginning with your primary school then secondary school and professional healthcare school. 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 the authorized issuing body.
Include a clear copy of your secondary school credential. Examples of this would be: a secondary school diploma, results of an external 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 following sentence, referred to as a “Certificate of Accuracy,” must be typed or written at the end of the translation and must be signed by the translator. It does not need to be notarized. Transcripts from secondary schools do not need to be translated by an official 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].” • 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 awarded based on the results of an external exam (for example, GCE, GCSE, Irish Leaving Certificate, WAEC), you may ask the examining board 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 school principal; headmaster or an examining board official; and, contain the school’s or examining board’s stamp or seal. If the letter is not in English, include a literal translation with a Certificate of Accuracy signed by the translator.
4 CGFNS Credentials Evaluation Service Applicant Handbook
• Form V Applicants educated in countries where completion of “Form V” is considered completion of secondary school, may submit one of 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/License
a. 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, an educational institution, or a potential employer. For each recipient, indicate the type of report and purpose of the request. You automatically 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 Fee
The 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 this section. Note that any money submitted to CGFNS/ICHP will first be applied to any unpaid balance from previously ordered products 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 12 months 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 Application
This 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 your application. After reading it carefully, sign and date the form. By signing the form, you certify that no portion of the documents submitted to CGFNS on your behalf is falsified, altered or tampered with by any person. CGFNS and others will rely on this application 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 in any CGFNS programs. The consequences could adversely affect your professional license, immigration status, employment and other matters.
Sign the Application Form with the same name you indicated in Item 3 of the application. You will be required to use the same signature each time you correspond with CGFNS or when CGFNS asks for your signature. The resulting CGFNS Credentials Evaluation Report will be issued using the name provided on your application. The Application Form does not need to be notarized.
CGFNS Credentials Evaluation Service Applicant Handbook 5
If You Choose to Mail Your Application
After completing your Application Form, send it to CGFNS, along with a photocopy of your secondary school diploma, and all required fees. Send your application materials to the following address: CGFNS Attn: CES Application 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651 USA CGFNS does not return any of the documents that are part of your complete application.
Chart 2: Checklist To Prevent Common Application Form Problems
Check 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. Remember to send readable photocopies, not originals, of the documents CGFNS requests directly from you. Applications remain open for one year (12 months).
Preparation and Mailing of Academic Records Form
To give CGFNS the necessary information about your education, you will need to send one copy of the Request for Academic Records form to each healthcare or post-secondary school that you attended outside the United States to ask them to send us your academic records. Provide all of the requested information on the front (the applicant's side) of the form before sending the form to each 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 accept records supplied by you or anyone else other than the school. If we receive foreign-language documents without an English translation, we can have them translated for the fee stated on the fee schedule, at your request.
Preparation and Mailing of Validation of Registration/License Form
You must request validations for your current and initial registrations/licenses obtained outside the U.S. To do this, use the Request for Validation of Registration/License for Credentials Evaluation Service form included in this applicant handbook. If you need to validate more than one registration or license credential, make photocopies of the blank form. Complete the front of the form (the applicant's side) and mail it to the authority that issued your registration or license. The section titled “For Registration Authority Use Only” is to be completed by your licensing agency. If you have a diploma that authorized you to practice in your country, send this form to the institution that issued your diploma (for example, your school or the Ministry of Health) and request that an official copy of the diploma in the original language be sent to CGFNS. Further information may be required after your file is initially reviewed.
Additional Requirements for New Jersey and Michigan
The New Jersey Board of nursing requires proof that the applicant has achieved a passing score on the English Proficiency Examination required by the Department of Homeland Security for certification of healthcare workers in Section 343 of the Illegal Immigration Reform Immigrant Responsibility Act of 1996. The Michigan Board of Nursing also requires proof of English Language Proficiency for applicants who graduated from a nursing school program that was taught in a language other than English. The CGFNS CES Report must be accompanied by this English language Proficiency Report containing the passing scores of the approved English examinations detailed in the CGFNS VisaScreen® handbook.
6 CGFNS Credentials Evaluation Service Applicant Handbook
Falsified or Altered Documents
If CGFNS finds that your documents have been altered in any way or that information in your application is false, whether submitted by you or on your behalf by another person, CGFNS will not issue a Credentials Evaluation Service Report on your behalf. 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 for future CGFNS/ICHP services.
If you have changed your legal name, CGFNS can make the change in your application file when we receive your signed, written request with legal proof of name change. Requests to change your mailing address must be in writing or you may make the change online through the CGFNS website. In your letter requesting any of these changes, remember to include your CGFNS ID Number and birth date. E-mail requests for change of name and address will not be accepted at any time.
Re-Process an Application
Applicants applying for the Credentials Evaluation Service will be given 12 months to meet the requirements of the program. Orders for the Credentials Evaluation Service that have not resulted in the issuing of a Credentials Evaluation Service report within 12 months of the application date will be expired. Once an order is expired, an applicant can re-apply with a re-process application and pay a second year re-process an expired order fee. Re-process orders remain open for 12 months starting from the date the re-process order is placed. A re-process order cannot be placed until the previous order is expired.
Guidelines for Communicating with CGFNS
If 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 the following guidelines to make this communication easier (see Chart 3 on page 8 for additional information).
You may access the CGFNS website for information on CGFNS and its programs, services and activities, application forms, and the On-line Application System at www.cgfns.org. To login and check your status, you must create a username and password.
If you want someone else to be able to access information from your confidential files, you must complete an Authorization to Release Information form and return the completed form to CGFNS. We will not release information to anyone other than the applicant without an Authorization form. You can revoke this authorization in writing at any time by sending CGFNS a signed letter stating that you revoke the Authorization. Authorization to Release Information forms are available on CGFNS’s website at www.cgfns.org or on page 11 of this Handbook.
Applicants may contact the CGFNS Customer Service Department with questions regarding their application by e-mail at www.cgfns.org “Contact us”.
CGFNS treats your application as confidential, to be discussed only with you unless you have named an authorized agent. When you send a letter, it must be written and signed only by you. When you write to us, always include your CGFNS ID Number, full name, and birth date. CGFNS recommends that you send all correspondence by first-class mail, and that you consider other faster mailing options when time is limited.
An applicant or authorized agent may make an appointment to discuss the applicant’s file by scheduling a 30-minute appointment in 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
CGFNS Credentials Evaluation Service Applicant Handbook 7
The CGFNS Customer Service Department provides applicant status information by telephone to applicants only. CGFNS will not release information by phone to anyone else unless a completed and signed “Authorization to Release Information” form has been received from the applicant. If you wish to telephone, call our Customer Service Department at (215) 349-8767. To save time, have your 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 United States), 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 to keep 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 their identification 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.
CGFNS makes every effort to ensure that our communication with applicants is clear and timely. However, some events are out of our 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 any alternate arrangements.
Chart 3: Communication Guidelines
You wish to obtain copies of the CGFNS Credentials Evaluation Applicant Handbook.
Who Can Initiate Request?
E-mail through our website www.cgfns.org “Contact Us” , write, telephone or download from the web site. 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. E-mail through our website www.cgfns.org “Contact Us” , write or telephone. E-mail through our website www.cgfns.org “Contact Us”, write, or make changes online at www.cgfns.org via the On-Line Application System (CGFNS Connect). Write to CGFNS including legal documenation of name change
An individual can receive 1 CES handbook free of charge by mail. If ordering additional copies, the fee (and any shipping costs) must be pre-paid. Include your Full Name, CGFNS/ICHP ID number and date of birth.
You want to confirm whether CGFNS received your application documents.
Only you or your authorized agent.
You have a question about a letter that you received from CGFNS/ICHP. You need to notify CGFNS of a change of address.
Include your Full Name, CGFNS/ICHP ID number and date of birth. Include your Full Name, CGFNS/ICHP ID number and date of birth.
Request should include signature, full name, CGFNS/ICHP ID number ID number and date of birth.
8 CGFNS Credentials Evaluation Service Applicant Handbook
Request For Academic Records For Credentials Evaluation Service
Dear Registrar:
(Applicants to complete this side)
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 English translation. My current name is: (Print or type your current name)
I attended (name of school) _________________________________ between (dates of attendance) ________/_______ and _________/______
Month / Year Month / Year
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: ___________________ My current address is:
Applicant Signature ____________________________________________
Address – Continued
State/Province Telephone Number Fax Number
Postal/Zip Code E-mail Address
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?____________________ Date of program completion Mo._________ Day _____ Yr______ What was the textbook language for the applicant’s program/course of study? _____________________________ Type of program (i.e. diploma, baccalaureate, midwifery) __________________________
No Is your school a government-approved school? Yes I hereby attest that the enclosed Academic Record Signature _________________________________________________________________ accurately states courses taken, hours of study, Sign and Print entire name, title and date and grades received for the above-named individual.
Please place school seal or stamp over flap of envelope after sealing and return the transcript/academic record(s) ALONG WITH THIS FORM via airmail to:
Credentials Evaluation Service CGFNS 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651, USA
School Seal or Stamp Must Cover 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 hours of theoretical instruction and hours of clinical practice in each subject area. All documents must be in English. Subjects Care of the Adult — Medical Nursing Care of the Adult — Surgical Nursing Maternal/Infant Nursing, excluding Gynecology Nursing Care of Children Psychiatric/Mental Health Nursing, excluding Neurology Gerontology Nursing Pharmacology Physiology Psychology Sociology Anatomy Nutrition
* Includes hours of classroom education, laboratory, and planned clinical conferences (ward teaching)
Hours of Theoretical Instruction*
Hours of Clinical Practice
Request forValidation of Registration/License For Credentials Evaluation Service
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 ______________________
Month __________________ Day ______ Year _______
The registration/license was issued under the name of:
Country Telephone Number Fax Number E-Mail Address
FOR REGISTRATION AUTHORITY USE ONLY:
1. This is to certify that ________________________________________________________ was first issued registration/license/diploma
number ____________ to practice as a ___________________________________________________ on: ______/_______/_______.
(Specify legal title) Month Day Year
The expiration date of this registration/license is: ______/_______/_______. Birth date of individual: ______/_______/_______
2. Authority to Practice: National/Provincial/State Examination Review of another license (endorsement) Registration Diploma Other: __________________________
3. Status Active/Current Inactive Expired Restricted*
*Please attach an explanation if the applicant’s registration/ license/diploma has ever been revoked, suspended, limited, or placed on probation.
4. Name and location of professional education program completed: ______________________________________________________ 5. Date of graduation: ______/_______/_______
6. Professional education program accredited/government approved? 7. Type of Program: Diploma Associate Degree
By Whom? ________________________________
Baccalaureate Degree Other (specify) ___________________________________ Date: _______/_______/_______
8. Signature of registration authority
(Do not print)
Sign and Print entire name
Registration authority title: ____________________________________ State/Province and Country: _______________________________________ Please send this document and any attachments in English, in the enclosed envelope. Sign your name over the flap after sealing. Send via airmail to: Credentials Evaluation Service CGFNS 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651, USA
Registration Authority Seal or Stamp Must Cover Signature
NOTICE: By signing below you: (1) allow CGFNS/ICHP to disclose confidential, personal, private information about you and your file 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 claims of 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 by CGFNS/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 that CGFNS/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 and my application/order for services from CGFNS/ICHP, including without limitation, the status of my application/order, the results of any credentials 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)
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 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.
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 your MasterCard & Visa cards in the signature area of the card. (It is the last 3 digits AFTER the credit card number in the signature area of the card).
Credit Card Type (check one): CGFNS does not accept American Express
Credit Card #: Expiration Date: Total Charges (see “Fee Schedule”): *CVV2 Number
(See explanation on other side.)
Name of Cardholder (as it appears on card): U.S. $
Cardholder Address: (For processing credit card payments only. All materials requested will be sent to the applicant address provided on the appropriate forms.)
Cardholder Signature (authorization for payment): I hereby authorize a charge to my credit card for the total of all services requested on the attached Certification Program Application Form, including any fee adjustments in effect as of the date the order is received.
Signature of Authorized Cardholder
2008 Application
1 Our Commitment to Service
CGFNS International • 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 U.S.A. • Phone: 215.222.8454 • Web: www.cgfns.org
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? Yes No Order # (if known) __________
If you already have a CGFNS/ICHP Identification Number, enter it here. A. Intended U.S. State(s) of practice _____________________________ .
B. I worked in ________________________________ as a __________________________________ for _______ years.
City/Country Profession Specialty Number
Enter your full, legal name as you would like it to appear on the report. Print or type only one letter in each box.
First and Middle Names (Leave a space between names)
Last (Family) Name (Leave a space between names)
Your Other Names
Enter alternate names appearing in your documents. Include legal documentation verifying each name change (for example: marriage certificate).
Name Before Marriage Other Names (for married women only)
5a Permanent Address
Indicate the address where you reside.
Street Address/ Post Office Box Number
5b Mailing Address
Provide the address where you want to receive your mail.
□ Single (Never Married) □ Divorced □ Widowed
7 Your Birth Date
Spell the month, enter day and year of birth.
Gender □ Female
Country of Birth ____________________________________
State/Province _____________________________
Citizenship ID Number_________________________ Native Language _________________________________ Current Citizenship __________________ Country of Initial Professional Education____________________
10 Your Telephone, Mobile (cell phone), & FAX Numbers and E-mail Address (if available) 11 Your U.S. Social Security Number 12 Institutions Attended
Pre-healthcare Profession Education List information for each school attended whether completed or not. Enclose a photocopy of your diploma, certificate, or external exam certificate from your secondary school, including word-for-word English translations of each of these documents. External exam results or school verification of graduation date must be submitted directly to CGFNS/ ICHP by the examining agency or school.
E-Mail Address (example: name@usenet.com)
Phone: Include Country Code/Area Code
FAX: Include Country Code/Area Code
May CGFNS send you a text message on your mobile (cell) phone? What is your preferred method of communication from CGFNS?
Yes Mail
Mobile (cell) : Include Country Code/Area Code Fill in your Social Security Number (if you have one)
Please list, in the order you attended them, all non-healthcare educational institutions, beginning with the first year of your primary school education and ending with the last year of non-healthcare education. Explain any gaps in your educational history. (Please fill in all spaces in the charts below completely or your application will be returned to you.) If your school has closed or merged, provide the name and address, if known, where your records are located.
Name of Non-healthcare Schools Attended City & Country Month/Year Month/Year Name of Diploma or Degree Obtained Certificate in its Entered Completed/ ( ) Graduated Original Language
Primary: Intermediate Secondary: Post-secondary non-professional programs:
Please list, in the order you attended them, all professional healthcare educational institutions. Explain any gaps in your educational history. Healthcare Education List information for each school attended whether completed or not. Forward a copy of “Request for Academic Records Form” to each school listed here.
Name of Professional Healthcare Schools Attended City, State/Province, Country Title Month/Year Month/Year Name of Diploma or Degree Obtained Obtained Entered Completed/ Certificate in its ( ) Graduated Original Language
Has your nursing school closed or merged with another school? □ Yes □ No If Yes, Name of School ______________________
13 Registration/ License
Forward a copy of “Request for A. If you are not currently registered/licensed, please indicate and explain. Validation of Registration/ □ Not currently registered/licensed □ Never registered/licensed License Form”to the authority Explanation: _____________________________________________________________________________________________ where you were initially registered/licensed and to all ________________________________________________________________________________________________________ authority(ies) where you are B. List your legal professional title(s) and country(ies) where you are currently licensed or have held a license. currently registered/licensed ________________________________________________________________________________________________________ outside of the U.S. 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.
14a Report Recipients
Name and Address of the First Recipient of Your Report
Indicate here the names and addresses of as many as two different recipients for your report. For each recipient, indicate the type of report and purpose of the request. NOTE: It is not necessary to list yourself; you automatically receive a copy of the report.
Name of Contact Person or Title
Address/Post Office Box Number
Ed. 3–2/08 ©2008 CGFNS. All rights reserved.
First Recipient (continued)
14b Type of Report
Refer to page 1 of Application Handbook for an explanation of both CES Reports. □ Healthcare Profession & Science Report □ Full Education Course-By-Course Report □ Academic Admission □ Other ________________________
14c Purpose of This Report 14d Name & Address of the Second Recipient of Your Report
□ RN Licensure □ Employment
□ LPN Licensure □ Immigration
□ Licensure Endorsement □ Certification
Indicate here the name and address of the Second recipient for your report. Indicate the type of report and purpose of the request.
14e Type of Report 14f Purpose of This Report 15a Credentials Evaluation Report Fees
□ Healthcare Profession & Science Report □ RN Licensure □ Employment □ LPN Licensure □ Immigration
□ Full Education Course-By-Course Report □ Academic Admission □ Certification □ Other ________________________
Select only one type of report. If you are requesting that two different types of reports be issued to two recipients, you should pay for the 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 Due
15b Total Application Fee
Full payment for all services requested must be included with your application. Send only a certified bank check or international money order, drawn in U.S. dollars on a U.S. bank, and made payable to “CGFNS,” or pay by credit card using the Credit Card Payment Form, or pay on-line at www.cgfns.org. Personal checks are not accepted. = $___________
16 Terms and Conditions of the CES
The following clarifies the obligations of the provider (CGFNS/ICHP) and applicant (you) of the Credentials Evaluation Service, 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.
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 submitted to 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 information submitted, and that if any of the items are falsified, altered or tampered with, or if I alter a CGFNS Certificate or a CGFNS Report or misrepresent a copy as an original, CGFNS may take such disciplinary action against me as it deems appropriate, and the consequences could adversely affect my professional license, immigration status, employment and 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 CGFNS Certificate, any reports or evaluations prepared by CGFNS, any other information obtained by CGFNS, and the results and reasons for any adverse action taken against me by CGFNS, to any person or organization I designate in writing or to any other recipient which CGFNS may determine has a legitimate interest in receiving the same, such as government 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
CGFNS Mission
Provide expert credentials evaluation and professional development services to promote the health and safety of the public.
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