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Academic Records Form Nurses

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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

/

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