CRP SCHOOL REQ RPT Academic Records Transcripts Form A

Request for Academic Records /
Transcripts
Order # 3634345
Applicant: *Please sign, date and send this form to your professional school (or where your Academic Records / Transcripts are archived) to have
an authorized official complete the remaining information.
Current Name: MICHELLE MADAYAG MAPILI

Name When Attended
School (if Different):
Other Names:
Name of School: URDANETA CITY UNIVERSITY (FKA CITY COLLEGES OF URDANETA)
Dates of Attendance: June 2008 to April 2012 Date of Birth: July 19, 1992
Email: michellemapiliRN@gmail.com Telephone:
336 NANCAMALIRAN EAST

Mailing Address:
URDANETA CITY,PANGASINAN 2428-PHILIPPINES
I, MICHELLE MADAYAG MAPILI, hereby give my consent to URDANETA CITY UNIVERSITY (FKA CITY COLLEGES OF
URDANETA) to provide CGFNS International, Inc. the requested information with supporting nursing education documents.
Month (Jan, Feb, Mar, ....) Day Year

*Applicant Signature: *Date Signed: December 11 2023
Attention: This is a customized form for use only by the applicant and Institution identified below. Do not duplicate this form for
any other applicant or institution.
Questions?: Contact CGFNS International at +1 (215) 222-8454 Monday through Friday from 9:00 am to 4:00 pm (U.S. Eastern
Time).
MICHELLE MADAYAG MAPILI | URDANETA CITY UNIVERSITY (FKA CITY COLLEGES OF URDANETA)
Order #: o3634345 | Doc ID #: DS2384812 | December 11, 2023 | Rev K:Mar. 2023 | Page 1 of 5
©2023 CGFNS International, Inc. All rights reserved
Request for Academic Records / Transcripts
Order # 3634345
To School Official,
1. Complete all areas on this form. All documents must have a certified English translation (if not in English).
2. Attach an official Academic Record / Transcript of this applicant's nursing education. This is the official documentation or record of this
applicant's courses, credits / clock hours, grades achieved, theory and laboratory hours, and clinical practice hours, and credentials earned. If
document is not in English, also include a certified English translation.
3. Place the school's official seal / stamp over the flap of the school's envelope (marked with a return address) that contains the completed form
and requested documents.
4. Send via postal mail (preferably trackable) to:
CGFNS International, Inc.

3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
USA
Student Date of Birth:

Student Name When Attended: Month (Jan, Feb, Mar, ...) Day Year
MAPILI, MICHELLE MADAYAG July 19 1992
School Name When Student Attended:

URDANETA CITY UNIVERSITY
Current School or Authority Name Where Academic Records / Transcripts are Archived (if different name):
CITY COLLEGES OF URDANETA
Current School Street Address (P.O. Box, if needed):
SAN VICENTE WEST
City: State / Province: Postal Code: Country:

URDANETA CITY PANGASINAN 2428 PHILIPPINES
School Telephone Number: School Web Address:

075-632-0455 www.ucu.edu.ph
School Registrar Contact Email: School Registrar Fax Number:
ucureg@ucu.edu.ph 075-632-0455
Time).
Order # 3634345
Please provide specific theory and clinical hours for all nursing domains and subject areas listed below. Please DO NOT combine the nursing
domains or subject areas. If they are combined in your curriculum, estimate the theory and clinical hours in each nursing domain and each subject area.
Clinical Education
Theory Hours *Clinical Hours
Nursing Domains Occurred:
Attained Attained (Instructions below)
1 Adult – Medical Nursing 1 2 3 4
144 306
2 Adult – Surgical Nursing 90 153 1 2 3 4
3 Maternal/Infant (excluding Gynecology) 72 204 1 2 3 4
4 Nursing Care of Children 90 306 1 2 3 4
5
Psychiatric/Mental Health (excluding 54 96 1 2 3 4
Neurology)
Clinical Education
Theory Hours *Clinical Hours
Subject Areas Occurred:
Attained Attained
(Instructions below)
1 Community Health Concepts 1 2 3 4
54 102
2 Geriatric Nursing (Gerontology) 54 96 1 2 3 4
3 Physical Assessment 54 51 1 2 3 4
4 Anatomy and Physiology (including 90

Body Structure and Function) Instruction Box
5 Ethical Considerations
32 Instructions
6 Health Counseling
32 Circle one number per row
7 Human Growth and Development
Throughout the Lifespan 32 Answers are required for each to show when the Clinical
8 question outside of this instruction Education Occurred
Interpersonal Relationships
32 box. 1: Same Semester as
9 Leadership in Nursing Theory
54
10 DO NOT LEAVE ANY BLANKS. 2: Within six (6) months
Legal Aspects in Nursing 54 of Theory
11 Personal and Family Health Concepts 32 Enter N/A if not applicable. 3: More than six (6)
12 months after Theory
Nutrition
54 4: By end of Program
13 Pharmacology and Administration of
Medications 54
14 Professional Roles & Functions 32
* Do not include classroom education, laboratory, simulation, and planned clinical conferences (ward teaching) hours. CGFNS International must have
the breakdown of theory hours and applicable clinical hours for all nursing domains and subject areas.
Time).
Order # 3634345
School Official, please complete all areas:
Language in which Student was Instructed Textbook Language of Student's Program / Course of Study:
English English
Course of Study (e.g., Nursing / Practical / Psychiatric / Midwifery): Name of Certificate / Diploma / Degree Obtained in Original Language:
Nursing Bachelor of Science in Nursing
Program Type (Mark only one):
☐ ☐ Certificate ☐ Associate Degree X Baccalaureate's Degree ☐
☐ ☐
Master's
Diploma Degree Doctorate
☐ Other (specify):
Attendance Dates:
Month (Jan, Feb, Mar, ...) Year Month (Jan, Feb, Mar, ...) Year Did the Applicant Complete the Program? (Mark only one):
Yes – Did
June 2008 to April 2012 X Complete No – Did Not Complete
Was this School Accredited or Government Approved When Student

Completed the Courses or Graduated? If Yes, Name of Organization that Accredited or Approved this School:
(Mark only one): X Yes No Commission on Higher Education
If Yes, Initial Date School was Accredited or Approved: If Yes (and renewed) , Last Date School was Renewed Accredited or Approved:
Month (Jan, Feb, Mar, ....) Day Year Month (Jan, Feb, Mar, ....) Day Year
February 1966 N/A
Was this Nursing Education Program Accredited or Government
Approved When Student Completed the Courses or Graduated? If Yes, Name of Organization that Accredited or Approved this Nursing Education Program:
(Mark only one): X Yes No Commission on Higher Education
If Yes, Initial Date Nursing Education Program was Accredited or If Yes (and renewed) , Last Date Nursing Education was Renewed Accredited or Approved:
Approved:
Month (Jan, Feb, Mar, ....) Day Year Month (Jan, Feb, Mar, ....) Day Year
June 17 1985 N/A
I (an authorized school official) hereby attest that the information provided on this form is accurate and the enclosed Academic Records /
Transcripts accurately states the courses taken by MICHELLE MADAYAG MAPILI. Please sign, print name, date and PLACE
OFFICAL SEAL / STAMP BELOW (without a signature, printed name, title, date signed and official school seal / stamp these documents
will not be accepted).
Month (Jan, Feb, Mar, ....)
Day Year
School Official Signature:
Print Name of School Official: Dr. Alyssa Ashley R. Diego School Official Title:
Acting Dean, College of Health Sciences
Place School Authority's

Seal / Stamp anywhere in this box.
Time).
INCLUDED DOCUMENTS CHECKLIST
Required Documents: Please indicate the number of pages for each required document to
make sure that all documents are accounted for. If the document is not paper, please indicate this by
writing "E-media".
Enter Number of
Required Documents
Pages
Academic Records Form (This form) Included 5 Page(s)
Official Records / Transcript Included 5 Page(s)
Additional Documents: When any additional documents are included, please explain:
Enter
Additional Document Number of
Pages
Description of Additional Document:
Included Pages
Missing Documents Explanation: CGFNS will likely refuse packages that lack required items,
as we cannot conduct the necessary evaluation for the applicant. If you cannot provide a mandatory
document, please provide an explanation in the space provided below:
Time).

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CRP SCHOOL REQ RPT Academic Records Transcripts Form A

Uploaded by

Copyright:

Available Formats

Request for Academic Records /

Current Name: MICHELLE MADAYAG MAPILI

Name of School: URDANETA CITY UNIVERSITY (FKA CITY COLLEGES OF URDANETA)

Email: michellemapiliRN@gmail.com Telephone:

336 NANCAMALIRAN EAST

Month (Jan, Feb, Mar, ....) Day Year

CGFNS International, Inc.

Student Date of Birth:

School Name When Student Attended:

City: State / Province: Postal Code: Country:

School Telephone Number: School Web Address:

3 Maternal/Infant (excluding Gynecology) 72 204 1 2 3 4

4 Nursing Care of Children 90 306 1 2 3 4

4 Anatomy and Physiology (including 90

Was this School Accredited or Government Approved When Student

School Official Signature:

Place School Authority's

Official Records / Transcript Included 5 Page(s)

Description of Additional Document:

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