CREDENTIAL EVALUATION APPLICATION FORM Diploma holders

CREDENTIAL EVALUATION APPLICATION FORM
Diploma holders / Organizations / Municipalities




1.
This document counts six pages. Please complete all the pages and don't forget to put your
signature at page five. At page six you can find the explanation about the payment for a credential
evaluation.
A number of questions are marked with *. This means that you will find more information on these
questions in the explanation document to the application. Please read the explanation document
carefully, while filling in the form. Additional documents could be required.
Sometimes, an evaluation of the diploma and/or certificate is not possible. In this case you will
receive a Bericht Geen Waardering. A Bericht Geen Waardering is issued after a substantive
assessment of the application by the respective country expert.
We do not return the documents you have submitted. Therefore, please do not send original
diploma's and lists of subjects, but always copies.
A credential evaluation only concerns the documents which you enclose with the application.
Who is applying for a credential evaluation?*
□
□
□
□
2.
Type of application*
□
□
3.
Diploma holder
Private company
Municipality
Other, namely________________________________________
Regular application
€ 123,-
Urgent application
€ 176,-
Data of applying organization
(If you apply as a diploma holder for an evaluation, then please skip question 3)*
3a
Name of organization:____________________________________________________
3b
Address / P.O. Box: _______________________________________________________
3c
Number: ________________________________________________________________
3d
Postal code: ______________________ Town: ________________________________
3e
Country: ________________________________________________________________
3f
Phone number: __________________________________________________________
3g
Contact person: □ m / □ f
3h
Family name of contact person: __________________________ Initials:_________
3i
E-mail address contact person: ______________________________________
January 2016
1 of 6
4.
Data of the holder of diploma/certificate + address where you want to receive the
credential evaluation
4a
Family name: _______________________________________________________________
4b
Family name as mentioned on diploma/certificate*: ______________________________
4c
Given name(s): ______________________________________________
4d
Address / P.O. Box*:__________________________________________________________
4e
Number: ___________________________________________________________________
4f
Postal code:__________________
4g
Country:____________________________________________________________________
4h
E-mail address:______________________________________________________________
4i
Phone number: ______________________________________________________________
4j
Date of birth*: ________________________________________________________________
5.
Data of the to-be-evaluated diploma (as stated on the diploma/certificate)
5a
Country of certification: _______________________________________________________
5b
Name of diploma to be evaluated*: ______________________________________________
5c
Year of issue*:_______________________________________________________________
5d
□
□
Sex: □ m / □ f
Town:_____________________________________
Education completed?*
Yes
No, I did not finish my study, but followed classes till the year _______.
Total duration of the entire study is _________ year.
5e
Branch of study: _____________________________________________________________
5f
Name educational institute: ____________________________________________________
5g
Language of the documents:___________________________________________________
6.
Purpose of the application
□
I want to work as a_________________________________________(please mention profession)
□
I want to work in a regulated profession ('protected profession'), but first I would like to have a
general evaluation of my diploma.
□
Combination of study and work, that is _____________________________(please mention study)
□
I participate in a naturalization procedure (inburgering)
□
Other reason, that is (please explain) ________________________________________________
January 2016
2 of 6
7.
Overview educational background*
Please fill in the schedule below, including the diploma that should be evaluated.
Education and training
Period
Duration of education
Diploma obtained?
according to education
When?
Education and training (use
plan
original names, if possible)
Primary education
from _____
_________________________
to _______
General secondary education
from _____
___ years
□ Yes / □ No
in year ______
___ years
to _______
□ Yes / □ No
in year ______
_________________________
Senior secondary vocational
education and training
from _____
___ years
to _______
□ Yes / □ No
in year ______
_________________________
from _____
___ years
□ Yes / □ No
_________________________
to _______
Higher professional education /
University
from _____
in year ______
___ years
to _______
□ Yes / □ No
in year ______
_________________________
_________________________
from _____
___ years
to _______
8.
□ Yes / □ No
in year ______
Relevant work experience*
Please complete the schedule below regarding relevant work experience. This is not obligatory. This
information could possibly be used for additional advice.
Professions / jobs
Period
Total duration of the profession / job
_______________________
from ____ till _________
______ year(s)
_______________________
from ____ till _________
______ year(s)
_______________________
from ____ till _________
______ year(s)
January 2016
3 of 6
9.
Checklist minimal required documents
For an evaluation of your diploma/certificate, the following documents are required. We therefore ask you to
send these documents directly with the application. This will avoid delays in the processing of the
application. Without these documents, we cannot evaluate your diploma/certificate.
On page 3 of the 'Explanation document application for credential evaluation' additional requirements are
indicated.
Tick the box in case the documents are enclosed in the application.
Minimally required documents which you should always enclose:
□
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(s) of subjects / list(s) of results of all the followed study years,
mentioning the name of the diploma holder, and as issued by the educational institute*.
□
9d
A copy of the sworn translation of the diploma/certificate and the official list(s) of
subjects / list(s) of results*.
□
9e
A copy of a valid identification card or passport*.
Documents which you need to enclose in some cases. See also page 3 of the explanation document.
□
9f
A copy of the preceding diploma and of the official list(s) of subjects / list(s) of
results of all the followed study years, mentioning the name of the diploma holder, and as
issued by the educational institute*.
□
9g
A copy of the statement of approval of UWV for a credential evaluation.
□
9h
If you have a diploma from one of the countries mentioned below: by ticking this box,
you indicate that you are aware of these additional requirements*.








Canada
United States of America
All countries in Africa, except Egypt, Libya, Morocco, Algeria, Tunisia, Sudan and
Mauritania
Poland
Morocco
Sri Lanka and Malaysia
Singapore, Thailand and Taiwan
China
10. 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 friends / acquaintances / co-workers
Via EP-Nuffic
Via DUO
Other, __________________________________________________ (please specify)
January 2016
4 of 6
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 send this completed application form, including the requested documents (no
originals) by post to:
IcDW (Information Centre for Credential Evaluation)
P.O. Box 7338
2701 AH Zoetermeer
The Netherlands
You can also send the application via e-mail to [email protected]
If
-
you send the request by e-mail, we ask you to send the application as follows:
Documents should be supplied as a PDF file (no zip-file)
Documents have to be scanned in color; we cannot accept pictures and images
All text and any frames, rims and stamps must be clearly readable
The e-mail should have a maximum of 7 MB
More information about credential evaluation can be found at www.idw.nl
You will find an instruction on the payment of your application on the next page.
January 2016
5 of 6
HOW CAN I PAY FOR A CREDENTIAL EVALUATION?
In the following schedule you can find information about the different procedures, costs and handling time.
Type of application
Regular application
Costs
€ 123,-* per diploma
Urgent application
€ 176,-* per diploma
Handling time
4 working weeks, once the application is paid for and
complete
2 working weeks, once the application is paid for and
complete
*VAT is not applicable for these costs.
No rights can be derived from the handling times.
Please use the checklist in the application form, to ensure that your application is complete. This enables us
to deliver your evaluation more quickly.
For payments from within the Netherlands:
IBAN-number NL46 RABO 0167 8898 34 on behalf of SBB, Zoetermeer.
Please state the family name of the diploma holder as well as his/her date of birth.
For payments from abroad:
IBAN-number: NL46 RABO 0167 8898 34
BIC-number: RABONL2U
Accountholder: SBB, P.O. Box 7259, 2701 AG Zoetermeer, The Netherlands
Name bank: Rabobank
Location bank: Zoetermeer, the Netherlands
Please state the family name of the diploma holder as well as his/her date of birth.
For international payments, please note :
a foreign bank can impose transaction fees on payments from abroad. These costs are for you as the
applicant.
Therefore, choose the option 'Our cost' (OUR) during the transaction, and not the option 'Shared cost'
(SHA). Your bank can inform you whether this is possible.
January 2016
6 of 6