CREDENTIAL EVALUATION APPLICATION FORM Diploma holders/ Organisations / Educational Institutes / Municipalities

CREDENTIAL EVALUATION APPLICATION FORM Diploma holders/ Organisations / Educational Institutes / Municipalities
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    January 2014   1 of 6   CREDENTIAL EVALUATION APPLICATION FORM Diploma holders/ Organisations / Educational Institutes / Municipalities    This document counts 6 pages. Please complete all the pages and don't forget to put your signature at page 5.    Please read the explanation document carefully, while filling in the form. This will avoid possible misunderstandings. For certain countries additional documents are required.    If we cannot issue a credential evaluation, you will receive a Besluit Geen Waardering .   This is a statement, mentioning that the diploma and/or certificate cannot be compared with a level or qualification in the Dutch educational system. When a Besluit Geen Waardering  is issued, there will be no refund of paid costs.    Do not   send srcinal documents, but always copies. We do not  return the documents you have submitted.    If you have questions about completing this form, you can contact our office "Information Centre Credential Evaluation". Our office is open from Monday till Thursday between 9:00 am and 12.30 pm, telephone number +31 (0) 79 321 79 30.   1. Who is applying for a credential evaluation? □   Diploma holder □   Private company □   Funded educational institute □   Municipality   □   Diploma holder, with permission of UWV (Dutch public employment service)   □   Other, namely________________________________________ 2. Type of application □   Regular application € 123,- □   Urgent application € 176,- □    Application funded educational institute 3. Data of applying organisation: (only fill in this part, if you apply through an organisation. If you apply as a diploma holder, you can go directly to question 4) 3a Name of organisation:_________________________________________________ 3b Address / P.O.Box: ___________________________________________________ 3c Number: ____________________________________________________________ 3d Postal code and town: ________________________________________________ 3e Country: ____________________________________________________________ 3f Phone number ______________________________________________________ 3g Contact person: Male / Female 3h Family name of contact person: __________________________ Initials:________ 3i E-mail address contact person : _____________________________________    January 2014   2 of 6   4. Data of applicant (holder of diploma/certificate) 4a Family name: _______________________________________________________ 4b Family name as mentioned on diploma/certificate: __________________________ 4c Given name(s): ______________________________________________ Sex: M / F 4d Address for correspondence:___________________________________________ 4e Postal code:____________ Town:_______________________________________ 4f Country:____________________________________________________________ 4g E-mail address:_______________________________________________________ 4h Phone number: _______________________________________________________ 4i Date of birth: _________________________________________________________ 4j Date of entrance in the Netherlands: ______________________________________ 5. Data of diploma to be evaluated  5a Country of certification: ________________________________________________ 5b Name of diploma to be evaluated: ________________________________________ 5c Year of issue:________________________________________________________ 5d Education completed? □   Yes □   No, I did not finish my study, but followed classes till the year _______. Total years of the entire study is _________ year. 5e Branch of study: _________________________________________________________ 5f Name educational institute: ________________________________________________ 5g Language of the documents:_________________________________________________ 6. Purpose of the application 6a Did you (or someone on your behalf) apply for a credential evaluation before? □   No □   Yes, at ______________________________ in the year: _____________ Did this concern the same diploma or certificate? yes / no 6b Why do you need a credential evaluation? □   I want to work as a_________________________________________(please mention profession) □   I want to work in a regulated profession ('protected profession'), but first would like a general evaluation of my diploma. □   Combination of study and work, that is _____________________________(please mention study) □   I participate in a naturalization procedure (inburgering) and I study Dutch to be able to work    January 2014   3 of 6   □   Other reason, that is (please explain) ________________________________________________ 7. Overview educational background Please fill in the schedule below (to be filled out by the holder of the diploma/certificate)   Education and training   Education and training (use srcinal names, if possible) Period   Duration of education according to education plan   Diploma obtained? When? Primary education ………………………….. from…. to……… ….years Yes / No in year……. General secondary education ………………………….. from…. to……… ….years Yes / No in year……. Senior Secondary Vocational Education and Training ………………………….. from…. to……… ….years Yes / No in year……. ………………………….. from…. to……… ….years Yes / No in year……. Higher Professional Education / University ………………………….. from…. to……… ….years Yes / No in year……. ………………………….. from…. to………. ….years Yes / No in year…….    January 2014   4 of 6   8. Relevant work experience Please complete the schedule below regarding relevant work experience in the country of srcin as well as work experience in the Netherlands  (to be filled in by the holder of the diploma/certificate). This information is not obligatory and will not be used in the credential evaluation of your diploma, but could be useful for providing you with additional information (for more information on this matter, please refer to the 'Explanation document - Application for credential evaluation') Professions / jobs Period Total duration of the profession / job Written evidence attached? ……………………… from….. till ..… Duration …….years yes / no ……………………… from….. till ..… Duration …….years yes / no ……………………… from….. till ..… Duration …….years yes / no ……………………… from….. till ..… Duration …….years yes / no ……………………… from….. till ..… Duration …….years yes / no 9. Checklist minimal required documents The below mentioned documents are the minimal requirements for application of a credential evaluation. Please refer to the Explanation document - Application for credential evaluation for additional application requirements. Tick the box in case the documents are enclosed in the application. □   9a A completed   application form  for a credential evaluation. □   9b A copy of the diploma that has to be evaluated , as issued by the educational institute. □   9c A   copy of the official list of subjects / list of results  of the diploma to be evaluated, as issued by the educational institute. The official list of subjects / list of results has to be submitted in the srcinal language. □   9d A   copy of your valid identification card or passport . □   9e If necessary, a copy of the sworn translation  of both the diploma and the official list of subjects / list of results. □   9f If necessary, a copy of the statement of approval of UWV  for a credential evaluation. □   9g In case you have a diploma from one of the below-mentioned countries, please refer to the possible additional requirements on page 4 of the application guidelines. By ticking this box, you indicate that you understand these additional requirements and apply accordingly.   Canada   United States of America   All countries in Africa, except Egypt, Morocco and Tunisia   Poland    January 2014   5 of 6     Morocco   Sri Lanka and Malaysia   Singapore, Thailand and Taiwan   China 10. How did you find the Information Centre for Credential Evaluation? In order to offer you the best possible service, the Information Centre for Credential Evaluation (IcDW) would like to know how you found the IcDW. Therefore, we ask you to answer the following question. How did you find the Information Centre for Credential Evaluation? □   Via UWV WERKbedrijf □   Via the website www.werk.nl  □   Via my employer □   Via Google.com / Internet search engines □   Via a flyer / promotional material □   Via friend / acquaintances / co-workers □   Other, __________________________________________________ (please specify) 11. Signature Date of application: ________________________ (day, month, year) Signature holder of diploma/certificate: Signature contact applying institute  ____________________________ _____________________________ By signing this application form the applying institute guarantees the payment for the credential evaluation. By signing this application form the holder of the diploma/certificate declares to have honestly filled out all data. He/she also guarantees the exactness of the submitted documents. Also the holder of the diploma/certificate authorizes the applying institute to apply for a credential evaluation and to receive the credential evaluation for him/her. The data of the holder of the diploma/certificate will be listed in the register of the Information Centre for Credential Evaluation and the centres of expertise involved.   Please see the next page for an instruction for the payment of your application Send this completed application form, together with the requested documents (no srcinals) to: IcDW (Information Centre Credential Evaluation) PO Box 7338 2701 AH Zoetermeer The Netherlands More information about credential evaluation can be found at www.idw.nl 
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