Lisano International
Foreign Educational Credential Evaluation
P.O. Box 407 Auburn, AL 36831-0407 U.S.A. ......Telephone - (334) 745-0425
E-mail: LisanoINTL@AOL.com
COURIER ADDRESS: 1381 LEE ROAD 400, OPELIKA, AL. 36804
_________________________________________________________________________________________________

.........................................................................MEMBER..........................................................................
Association of International Credential Evaluators, Inc. (AICE)
National Association of Foreign Student Affairs: Association of International Educators (NAFSA:AIE)

Revised 2012

APPLICATION FOR EVALUATION: FOREIGN ACADEMIC CREDENTIALS
(Please print clearly or type)

_____________________________________________________________________

PLEASE READ INSTRUCTIONS BEFORE COMPLETING & SIGNING THIS FORM

1. Last/Family Name:____________________________________________(__) Mr. or (__) Ms.

First Name:_______________________________, Middle Name:_________________________

2. Date of Birth (M/D/Y):________________.Country of Citizenship______________________

3. Street Address & Number:________________________________________.Apt/Flat_______

City:______________________State_________________Country______________Zip_______

4. Day Tel. #: (___)_____________________Night Tel. #: (___)__________________________

Fax #: (___)__________________________E-Mail:____________________________________

6. PURPOSE OF EVALUATION: (Check all appropriate items)
(___) Further Education; (___) Immigration; (___)Employment,
(___) Professional Licensing/Certification; (___) Other:_________________________

7. TYPE OF EVALUATION REQUESTED: (See Instructions)
(___) Document-By-Document ($100.00 U.S.)

 

8. PROCESSING TIME REQUESTED: (See Instructions)
(___) Normal: Ten-twenty (10-20) working days.
(___) High Priority Rush: Three (3) working days (an additional $150.00 U.S.): Check Availability.

9. REPORT COPIES:
(___) 2 original, signed and sealed copies (no additional charge)
Additional copies - $10.00 (U.S.) each
.....# additional copies
.............(___) ................x $10.00 = $___________ (U.S.)

10. DELIVERY CHARGES:
(___) Regular U.S. mail (no additional charge)
(___) U.S. Postal Service 2-3 Day Priority Mail ($8.00 U.S.)
(___) Overnight Delivery Service (Domestic - $25.00 U.S.)
(___) Overnight Delivery Service (International - $50.00 U.S.)

11. Total number of years completed for primary/secondary education (elementary/junior
high/senior high school): (___) 10; (___) 11; (___) 12; (___) 13;

12. In your country, what is your "secondary school (high school) diploma" called in your
native language? For example is it a Bachillerato? Or Attestat Zrelosti? Or Baccalaureat? Or
Abitur? Or Maturia? Or Studentsprof?, etc. ________________________________________?

13. List, in chronological order, ALL colleges/universities which you attended, or are attending.
This must be completed accurately. Write all names of institutions and documents "in your
native language" and "in English. Please give the Name of Institution, City and Country,
Dates of Attendance, and "Diploma/Degree/Certificate" received. FOR EXAMPLE:

Novosibirskii Gosudarstvennyi Universitet, (Novosibirsk State University), Novosibirsk ,
Russia, 1981-84, "Kandidata Nauk"
a.____________________________________________________________________________

_____________________________________________________________________________

b.____________________________________________________________________________

_____________________________________________________________________________

c.____________________________________________________________________________

_____________________________________________________________________________

d.___________________________________________________________________________

_____________________________________________________________________________

 

14. One original, signed, and sealed copy of the Evaluation Report will be sent to you at the
address indicated in Item #3 above. If you wish, a second original, signed, and sealed copy of the
report will be sent (free of charge) to a third party. Please indicate name (s) and address (es)
below. All other copies require an additional charge--see "FEES" in the Application
Information Section.

(1)__________________________________________________________________________

____________________________________________________________________________

(2)__________________________________________________________________________

____________________________________________________________________________

15. AFFIRMATIONS: ( Please read, check all boxes, and sign with your legal signature).

(__) A. I hereby certify that all of the information provided in this application is true, accurate,
and correct.

(__) B. I certify that I have read ALL instructions for the Application, that I fully understand
them, and that I accept the conditions and terms stated therein.

(__) C. I fully understand that evaluation reports prepared by Lisano International are advisory
and not binding on any agency, organization, or institution which may use them. I release Lisano
International from any liability if the equivalency anticipated by me is not recommended, and
further agree that Lisano International shall not be responsible for any incidental or
consequential damages which I may incur from the use of an evaluation report by me or any
third party.

(__) D. I have checked with the agency or institution to which this evaluation is to be sent to
ascertain the type of report needed and that evaluations by private evaluation services are
acceptable.

Signature :_____________________________________ ,

Today's Date:_____________

Name (Printed):__________________________________________________________

Return the completed application to Lisano International with the following:
................1. CERTIFIED PHOTOCOPIES OF ALL ACADEMIC RECORDS (see Instructions)
................2. CERTIFIED ENGLISH TRANSLATIONS OF ALL ACADEMIC RECORDS
................3. CERTIFIED BANK CHECK OR MONEY ORDER PAYABLE TO LISANO INTERNATIONAL

How did you learn about this evaluation service?

______________________________________________________________________

___________________________________________________________________Thank You!

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