Academic Records Form Nurses
Request for Academic Records/Transcripts
FOR APPLICANT TO COMPLETE BEFORE SENDING TO SCHOOL
NURSES
My current name
First (given) name Middle name Last (family / surname) name
Name of school I attended I attended between the dates of
Month Year
and
Month Year
My birth date
Month Day Year
My name when I attended this school
First (given) name Middle name Last (family / surname) name
My other names
My CGFNS ID number (if known) Applicant signature My current mailing address
Address
My order number (if known)
Address
City
State / Province
Post / Zip code
Country
Telephone number (include country code and area code)
Fax number (include country code and area code)
Email address
FOR SCHOOL TO COMPLETE
Dear Registrar: Please complete this section of the form and send it to CGFNS along with the above applicant’s academic records/transcripts listing the courses taken, hours of study and grades earned, accompanied by a certified English translation. 1. Applicant name 2. In what language was the applicant instructed? Applicant’s birth date / /
Month
Day
Year
3. What was the textbook language for the applicant’s program/course of study? 4. Program type (e.g., diploma, baccalaureate) 5. Attendance dates
Month Year
Course of study Did applicant complete program ?
Month
to
Year
n Yes
n No
6. School name 7. School address
SEAL OR STAMP
Address Post / Zip code
City
State / Province
Country
Continued on following page
© Copyright 2011 CGFNS International. Revised May 2011.
Request for Academic Records/Transcripts
FOR SCHOOL TO COMPLETE, page 2
NURSES
8. School telephone 9. School email address 10. Is this school accredited or government approved? By whom? Is this educational program accredited or government approved? By whom? n Yes n No
School fax School web address
Date accredited or approved n Yes n No Date accredited or approved
Month
/
Day
/
FOR APPLICANT TO COMPLETE BEFORE SENDING TO SCHOOL
NURSES
My current name
First (given) name Middle name Last (family / surname) name
Name of school I attended I attended between the dates of
Month Year
and
Month Year
My birth date
Month Day Year
My name when I attended this school
First (given) name Middle name Last (family / surname) name
My other names
My CGFNS ID number (if known) Applicant signature My current mailing address
Address
My order number (if known)
Address
City
State / Province
Post / Zip code
Country
Telephone number (include country code and area code)
Fax number (include country code and area code)
Email address
FOR SCHOOL TO COMPLETE
Dear Registrar: Please complete this section of the form and send it to CGFNS along with the above applicant’s academic records/transcripts listing the courses taken, hours of study and grades earned, accompanied by a certified English translation. 1. Applicant name 2. In what language was the applicant instructed? Applicant’s birth date / /
Month
Day
Year
3. What was the textbook language for the applicant’s program/course of study? 4. Program type (e.g., diploma, baccalaureate) 5. Attendance dates
Month Year
Course of study Did applicant complete program ?
Month
to
Year
n Yes
n No
6. School name 7. School address
SEAL OR STAMP
Address Post / Zip code
City
State / Province
Country
Continued on following page
© Copyright 2011 CGFNS International. Revised May 2011.
Request for Academic Records/Transcripts
FOR SCHOOL TO COMPLETE, page 2
NURSES
8. School telephone 9. School email address 10. Is this school accredited or government approved? By whom? Is this educational program accredited or government approved? By whom? n Yes n No
School fax School web address
Date accredited or approved n Yes n No Date accredited or approved
Month
/
Day
/