Professional Documents
Culture Documents
VSRenewal
VSRenewal
VSRenewal
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)
Othername(s)(leaveaspacebetweennames)
5 Gender
Female Male
7 Marital status
Married Divorced Widowed Single(nevermarried)
Street
City
State/Province
Post/Zipcode
Country
RevisedMay2011.Copyright2010-2011CGFNSInternational.Allrightsreserved.
Street
City
State/Province
Post/Zipcode
Country
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
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.
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.