REQUEST FORM FOR DUPLICATE COPIES OF AN EVALUATION
Please note that there is a two-year limit from the time a report is issued for requests for copies of any evaluation. After this date a new report and new application
fees are required. IERF reserves the right to deny a request for a duplicate copy on the basis of changes that may have taken place in: 1) the educational system
of the country of study, 2) IERF policy, or 3) the requirements of the institution/licensing board/agency to which the report is to be sent, since the time the initial
report was issued. In such a case, a new report and new application fees are required. A separate form is required for duplicates of nursing evaluations and
physical therapy evaluations.
Please complete this form clearly and return it with your payment to support@ierf.org or IERF, P.O. Box 3665, Culver City, California 90231-3665.
Section 1: Applicant Information
Name: ___________________________________________________________________________________________________
Family/Last Given/First Second/Middle
Mailing Address: __________________________________________________________________________________________
Number Street Apt. #
______________________________________________________________________________________________________
City State Zip/Postal Code Country
Telephone: ( ) ________________ ( ) _______________ Fax: ( ) _____________ Cell: ( ) ____________________
Day Evening
Email: ____________________________________________ IERF File # _____________________________________ (Please provide.)
Section 2: Fees
One official copy and one applicant copy are included in the fee.
Allow 10 business days for your report to be mailed.
DUPLICATE COPIES
First Copy $_______
Addi
tional Duplicate Copies ($25 each, if applicable) $_______
If
you have previously received more than one report type from our
office (i.e., General Report, Detail Report, etc.), please indicate which
report you would like a copy of:
________________________________________________
RUSH SERVICES Payment must be made by cashier’s check,
money order or credit card.
24-H
our Rush (add $100) $_______
5-Day Rush (add $50) $_______
MAILING OPTIONS – (prices are per address) *
Do
mestic (no P.O. Boxes)
Secure Mailing (add $20 each) $_______
address in Applicant Info Section 3 both
Next Day Delivery (add $35 each) $_______
address in Applicant Info Section 3 both
In
ternational (no P.O. Boxes)
International Secure Mailing (add $75 each) $_______
address in Applicant Info Section 3 both
TOTAL $_______
Section 3: Where should your official duplicate copy be sent? **
Mail the official copy and the applicant copy directly to me at the
address in Applicant Information (Section 1).
Mail the official copy to the address(es) below and the applicant
copy to me. Note the additional charge if you list more than one
address – see Fees (Section 2).
Name:
Address*:
Telephone: ( )
Name:
Address*:
Telephone: ( )
**
You must provide a street address when requesting Secure Mailing
or Next Day Delivery (no P.O. Boxes), as well as a phone number.
Section 4: Certification
I agree to be bound to the same terms and conditions as
those in my initial application.
Signature (required) Date
* Evaluations are sent via regular mail unless otherwise requested. There is no additional fee for regular mail. If submitting original documents, we recommend
that you select either Secure Mailing or Domestic Next Day Delivery for the return of your academic records. Please note that the original documents that you
submit will not be returned to you via regular mail, unless you instruct us in writing to do so. IERF accepts no liability related to the loss or damage of
documents during mailing.
For Office Use Only
Ref. #:
Date:
Fees:
RESEARCH FOUNDATION, INC.
Rev. 03/19
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