FCSA Application for Credentials Evaluation – Standard Application Form Page 2
Please type or write legibly. Any missing, illegible, or incomplete information may result in the delay or non-processing of your application. All
applications received after 2 PM CST will be considered to have been received the following business day. Applications may be sent by email, mail or fax to the contact
information shown at the top right-hand corner of the first page of this application.
Personal Information
First Name:__________________________________________________________
Middle Name:________________________________________________________
Last Name:___________________________________________________________
Other Name(s) that might appear on documents, including maiden names:
_____________________________________________________________________
Date of Birth (MM/DD/YYYY): ________________________________
Foreign Country(s) of Education: _________________________________
Gender: Male Female
Phone: ________________________ Fax: ______________________
E-mail: ______________________________________________________
(You will receive status updates and a copy of your evaluation at this address)
Employment University Admission
Referral Information: How did you hear about FCSA? _____________________________________
Summary of Educational Experience Use additional sheet of paper if necessary
Name of School and Location
Dates of Attendance (From – To)
Degree, Title or Certificate Year Earned or Expected
Payment Information
Enclosed US Check or US Money Order (Make payable to FCSA)
Credit Card
Visa
MasterCard
Notes, special requests: (For example: I need my report in a separate sealed envelope)
Name On Card____________________________________________________
Credit Card Number ______________________________________________
Expiration Date (xx/xx):____________________ CVV #________________
Authorization Signature__________________________________________
Signed Statement
Signature of Applicant/Contact __________________________________________________________________ Date_____________________________
Billing Address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Evaluation Services
Detailed Evaluation of Coursework ($150)
3 Working Days ($75)
One Day Service ($195)
Additional Copies can be purchased for $25 per report for up to four years.
Changes can be made to a completed report within two years.
American Express
Rev. 5/14/2020
Purpose of Evaluation (Please visit our website for specific instructions that may be applicable for evaluations intended for certain universities, licensing boards, etc.)
Note: Only the first and last name will be included on the report.
(required – see page 1 for a description of our services)
USPS without tracking (Free)
Domestic USPS, 2-3 business days with tracking ($10)
Domestic Expedited USPS, 1-2 business days with tracking ($25)
International DHL Express, 3-5 business days ($60)
*Required for all international addresses*
Other: _________________________________
City, State, Zip (Country, if not USA**):
___________________________________
___________________________________
___________________________________
________________________
Return my official ACADEMIC documents, if applicable, to the address above.
USPS without tracking (Free)
Domestic USPS, 2-3 business days with tracking ($10)
Domestic Expedited USPS, 1-2 business days with tracking ($25)
International DHL Express, 3-5 business days ($60)
*Required for all international addresses*
Additional Copy Shipping Address: ($25 per report)
Receiver's Name:
Street, Apt/Suite:
City, State, Zip (Country, if not USA**):
__________________________________
__________________________________
__________________________________
_______________________
Return my official ACADEMIC documents, if applicable, to the address above.
General Statement of Equivalency ($85)
Time-frame Options
Approximately 10 business days (free)
Shipping Options (the shipping time is not included in the time-frame options)
Complimentary Report Shipping Address:
Receiver's Name:
Street, Apt/Suite:
Shipping cost for Complimentary Report: ______
Shipping cost for Additional Report(s) +
Cost for the Additional Report(s) ($25/copy): _______
If you need additional space to request more reports, please attach another sheet of paper to
this application for the other addresses.
I certify that all information provided on this application is complete, factually accurate, and honestly presented. I certify that I have read the instructions and conditions and agree to the terms stated therein. I
understand that cancellations must be requested prior to the completion of the evaluation. A non-refundable processing fee of $25 will be deducted from all cancellations. I understand that if fraudulent
documentation is presented, an evaluation will not be provided, the application will be canceled, and a refund will not be processed. I understand that the evaluation is advisory and is not binding upon any agency
or institution that uses it nor guaranteed to be accepted or used by any agency or institution. I release Foreign Credentials Service of America from any liability for damages resulting from the use to which I or any
agency or institution puts the evaluation.
TOTAL cost:
