International Institute of California

(To print this page: Right-Click on the form and select "Print" from the pop-up menu)

PIN
Date

(Office use only)

3550 Stevens Creek Blvd., Suite #310 San Jose, CA, USA, 95117 Telephone (408) 249-1505 Fax (408) 249-3187 E-mail mulu@iicus.com

APPLICATION FORM

1. Applicant's Name (Last/Family)

First

Middle

2. Gender

Male

Female

3. Date of Birth

Month

Day

Year

4. Country of Birth

5. Country of Citizenship

6. Current Mailing Address

Street Address

Apt/Suite No.

City

State

Zip Code

7. Telephone

Daytime:

Evening:

Fax:

E-mail

8. PIN: (if any)

Personal Identification Number

USA SSN: (if any)

Social Security Number

9. Evaluation Request:

(see brochure for description)

(Check one please)

General Academic Work

Doctoral Work

Other: (Please Specify)

10.Type of Evaluation Requested:

(see description)

(Check one please)

	Summary Report
	Course Analysis

	Detailed Breakdown
	U.S Armed Forces

11. Do you need a rushed evaluation?

Yes

If your answer is yes, please check one:

	24 Hours
	5 Working Days

	3 Working Days
	10 Working Days
	15 Working Days

12. Do you need extra official copy:

Yes

If Yes, how many

13. This evaluation is intended for:

(Check one please)

Employer

College or University Admission

Other: (Please Specify)

14. Where do you want the evaluation to be mailed?

(Check one please)

Original and Copy to You

Original to the intended agency and copy to you

Please give the complete name and address of the agency:

1. List below all schools, colleges and universities in chronological order starting from primary school.

School Name	Dates Enrolled MM/YYYY	Units Completed	Degree Earned	Date Expected MM/YYYY

(Attach additional pages if needed)

2. How did you hear about IIC?

Friends

Brochure

A University or College

Language Schools

Internet

Other (Please Specify):

I have read and understand the terms and conditions described about this evaluation by IIC.

Name

Signature

Date

Please remember to enclose all documents with your application. Including: certificate(s), diploma(s), transcript(s), mark sheets, grade reports, course syllabus translations and fees. INCOMPLETE FILES MAY DELAY YOUR EVALUATION.

You may make copies of this form if you wish.

Please Note : "If you are first time applicant, please do not Submit. Print the form and mail along with payment and your documents" or for more info pls call 408-249-1505.

PLEASE MAIL TO

International Institute of California
3550 Stevens Creek Boulevard, Suite #310
San Jose, California - 95117
Telephone: (408) 249-1505
Fax: (408) 249-3187
E-mail: mulu@iicus.com