VisaScreen: Visa Credentials Assessment

Renewal Application
CGFNSInternational3600MarketStreet,Suite400,Philadelphia,Pennsylvania19104-2651USA +1(215) 2228454 www.cgfns.org

Provide all information requested on all pages. Note that inaccuracies will delay the processing of your application. Enter responses legibly. Submit original and retain a copy for your files. Mail the application to the address above. 1 Preliminary information
a. Ifknown,enteryourCGFNS/ICHPIDnumber b. IhavenotyetworkedintheUnitedStates c. Iworkedin
City/Country

Yes asa

No for
Professionspecialty Number

years

2 Your name
Enter your name as you would like it to appear on all correspondence and the VisaScreen certificate. Please print or type only one letter in each box.
First(given)andmiddlenames(leaveaspacebetweennames)

Last(family/surname)name(s)(leaveaspacebetweennames)

3 Other names (ifapplicable)

Please print or type all other names appearing in your documents. Include legal documents verifying name change (forexample:amarriagecertificate).
Namebeforemarriage

Othername(s)(leaveaspacebetweennames)

4 Birth date (spellthemonthandenternumbersforthedayandyear)

Month Day Year

5 Gender
Female Male

6 Your U.S. Social Security Number (Ifyouhaveone)

7 Marital status
Married Divorced Widowed Single(nevermarried)

8a Your mailing address (Note:YouareresponsiblefornotifyingCGFNSifyouraddresschanges)

Print or type the address where CGFNS will mail all your correspondence.
Street

Street

City

State/Province

Post/Zipcode

Country

RevisedMay2011.Copyright2010-2011CGFNSInternational.Allrightsreserved.

8b Your residential address (Pleasenote:YouareresponsiblefornotifyingCGFNSifyouraddresschanges)

Print or type the address where you reside.
Street

Street

City

State/Province

Post/Zipcode

Country

9 Your contact details

Telephone(includecountrycodeandareacode) Email(required) Mobilephone(includecountrycodeandareacode) Fax(includecountrycodeandareacode)

MayCGFNScontactyoutodiscussyourtransitiontopracticingintheUnitedStates? n Yes n No WhatisyourpreferredmethodofcommunicationfromCGFNS? n Postalmail n Email

10 License/Registration/Diploma
CompleteandsendaRequest for Validation of License/Registration/Diplomaformtoeverylicensingauthorityresponsibleforissuing/validating yourlicences/registration/diplomas.ThelicensingauthoritiesmustsendthecompletedformdirectlytoCGFNS/ICHP.CGFNSneedstoreceive updatedvalidationforeverylicenseyouhaveheld,pastandpresent,ifithasbeenmorethanthreeyearssincewehavereceivedvalidations ofyourlicensure.Ifyourdiplomaauthorizespracticeinyourcountry,forwardthisformtotheinstitutionthatissuedit(eg,school,Ministry ofHealth). Listcountries,statesandprovinceswhereyouhaveobtainedlicenses/registration/diplomasandthecorrespondingregistrationnumbers

Haveanyofyourlicenses/registration/diplomaseverbeenrevoked,suspendedorrestrictedforanyreason? n Yes n No IfYes,pleaseexplain

11 For which health care profession are you being screened?

Mark the title of the health care profession for which you are being screened. Mark only one. n Audiologist n Clinicallaboratoryscientist(medicaltechnologist) n Clinicallaboratorytechnician(medicaltechnician) n Licensedpracticalnurse/Licensedvocationalnurse n Occupationaltherapist n Physicaltherapist n Physicianassistant n Registerednurse n Speechlanguagepathologists

12 Occupational visa information

Indicate which U.S. visa you plan to obtain from the U.S. Government. n H1B n H1C n TN(status) n Permanent(Greencard) n Other

13 For which VisaScreen category are you applying?

n VisaScreencertificate n 212(r)CertifiedStatement Pleasenote:AVisaScreenrenewalcertificateisvalidforfiveyearsafterexpirationdateofcurrentVisaScreencertificate.Youshouldbegin therenewalprocesssixmonthsbeforeyourcurrentVisaScreencertificateexpires.
RevisedMay2011.Copyright2010-2011CGFNSInternational.Allrightsreserved.

14 English language proficiency

Non-exemptapplicantsmustsubmitEnglishlanguageproficiencyscoresfromeitherETS(EducationalTestingService)orIELTS(International EnglishLanguageTestingSystem).TOEFLiBTtestresultsmustbeelectronicallysenttoCGFNS/ICHPbyETSandIELTStestresultsneedto berequestedtobemadeelectronicallyavailabletoCGFNS.PleasenotethatyoumaysubmityourVisaScreenrenewalapplicationpriorto registeringfortheEnglishlanguageproficiencyexaminations. ETS administration dates
TOEFL-PBTtestdate: TOEFL iBT testdate: TOEICtestdate: Month Spellmonth Month Spellmonth Day Year Registration/Appointmentnumber Month Spellmonth Day Year Registration/Appointmentnumber Day Year Registration/Appointmentnumber

IELTS administration dates

Testdate: Month Spellmonth Day Year Testreportformnumber

Waiver of the English requirement TheEnglishrequirementcanbewaivedifyoucanprovideproofofU.S.employmentinthehealthcareprofessionlistedonyourVisaScreen certificate for at least 2736 months including nine months of the year before the date your renewal application is submitted. Your employer will need to submit an employment summary to CGFNS/ICHP on corporate letterhead with the appropriate signature for the Englishrequirementtobewaived.

15 VisaScreen Renewal Application fees and payment information

FeesforCGFNSservicesarelocatedonlineathttp://www.cgfns.org/sections/apply/fees.shtml#1andaresubjecttochange.Fullpaymentfor allservicesmustbemadebeforeyourapplicationanddocumentscanbereviewed.Ifyouuseacreditcard,youmaypayonlineathttps:// www.cgfns.org/cerpassweb/intro.jsporusetheCredit Card Payment Formlocatedathttp://www.cgfns.org/sections/apply/forms.shtml.We acceptVisa,MastercardandDiscover.Alternatively,youmaysubmitaninternationalmoneyorderorcertifiedbankcheckpaidinU.S.dollars, drawnonaU.S.bank,andmadepayabletoCGFNS.Personalchecksarenotaccepted.Pleasedonotsendcash.

16 Terms and Conditions of VisaScreen:Visa Credentials Assessment Renewal Application

The following clarifies the obligations of the VisaScreen provider (CGFNS/ICHP) and the applicant (you), as well as the manner in which this service is delivered. n GFNSmaychoosetoevaluateonlythedocumentsitconsidersrelevanttotheVisaScreenapplication. C n lldocumentssubmitted,includingacademicrecords/transcripts,becomethepropertyofCGFNSandwillnotbereturnedtoyou.Donot A sendoriginaldiplomas,degrees,certificates,registrationsorlicenses. n oevaluationisconducteduntilCGFNSreceivesacompleteapplicationandfullpayment.Pleaseincludepaymentwithyourapplication. N n eesaresubjecttochangeandarefoundathttp://www.cgfns.org/sections/apply/fees.shtml. F n nypaymentsenttoCGFNSwillbeappliedfirsttoanyunpaidbalancefrompreviousordersforproductsorservicesbeforeitisapplied A aspaymenttothisapplication. n orefundisgivenafteranapplicationissubmitted. N n heICHPVisaScreencertificateisvalidforfiveyearsonlywhentheofficialCGFNSandICHPsealsareaffixed. T n Ifyourapplicationincludesanyforged,alteredorfalsifieddocumentsorinformation,CGFNS/ICHPwillnotissueaVisaScreencertificate.

RevisedApril2011.Copyright2010-2011CGFNSInternational.Allrightsreserved.

17 Attestation
I agreetotheTermsandConditionsoftheVisaScreen: VisaCredentialsAssessmentRenewalApplicationoutlinedinItem16(above). IcertifythatallinformationthatCGFNS/ICHPhasreceivedasapartofthisapplicationnoworinthepastfrommeorfromathirdpartyon mybehalf,istrueandcomplete.IalsocertifythatalldocumentswhichhavebeensubmittedtoCGFNS/ICHPforanypurposehavenotbeen falsified,alteredortamperedwithbyanyperson. IunderstandthatCGFNS/ICHPandotherswillrelyonthisapplicationandonthedocumentsandinformationsubmitted,andthatifanyof theitemsarefalsified,alteredortamperedwithorifIalteranICHPVisaScreencertificateormisrepresentacopyasanoriginal,CGFNS/ICHP maytakeactionagainstmeasitdeemsappropriateandtheconsequencescouldadverselyaffectmyprofessionallicense,immigrationstatus, employmentandothermattersfromwhichIreleaseCGFNS/ICHPfromallliability. I authorize CGFNS/ICHP to disclose the information and documents in this application, the status of any CGFNS certificates, reports or evaluationspreparedbyCGFNS/ICHP,anyotherinformationobtainedbyCGFNS/ICHP,andtheresultsandreasonsforanyactiontaken againstmebyCGFNStoanypersonororganizationIdesignateinwritingortoanyotherrecipientwhoCGFNS/ICHPmaydeterminehasa legitimateinterestinreceivingthesame,suchasgovernmentagenciesandpotentialemployers. IunderstandthatCGFNS/ICHPmayrevokemyICHPVisaScreencertificateifitdeterminesthatIwasnoteligibletoreceiveitorthatitwas otherwiseissuedinerror. You must sign and date this application in order for it to be processed. Yoursignature
Signentirename

Printyourname

Date
Month/Day/Year

RevisedMay2011.Copyright2010-2011CGFNSInternational.Allrightsreserved.