AERC

American Education Research Corporation
P.O. Box 996 West Covina, CA 91793-0996
Education – Research – Development
Tel: (626) 339-4404
 
Fax: (626) 339-9081

 



 

Please check and complete all questions.  Blank answers may delay processing.  Type or print clearly.

  1. Applicant’s Name:



  2. Sex:
          


  3. Name as it appears on documents if different from above:



  4. Current mailing address:


  5. Home Phone:

  6. Work/Cell Phone:

  7. E-mail Address:

  8. Date of Birth (month/ day/ year):

  9. Place of Birth (State/ Country):

  10. Years of Education Completed. Begin from first grade (check one):
                                   

  11. List all educational institutions in chronological order, including high school and higher education.  Must be completed by all applicants requesting evaluation.  Add additional sheets if necessary.

    Name of Institution City/ Country

    Dates Attended, From/To

    Name of Certificate / Degree / Diploma Earned Graduation Date Major


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  12. Language of foreign records presented:

  13. Country of records:

  14. Language of Instruction:

  15. Purpose for which evaluation is intended:

  16. Intended major in the US:

  17. Name and address of institutions requesting evaluation(s):

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  18. Do you want a copy to be mailed directly to the above listed institution(s)?
          

  19. How did you learn of our services?

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IMPORTANT

  1. The undersigned has read, understood, and agrees to all terms and conditions specified in the applicant information section, and releases AERC from any liability for damages resulting from the use of this form. AERC is not responsible for documents lost, stolen, or damaged in the mail.
  2. The undersigned authorizes the above listed educational institutions to release information to AERC.
  3. The undersigned certifies under penalty of perjury that the information provided in this application and the records presented are true and correct to the best of his/her knowledge. Alteration or irregularities in records presented will result in such documents to be impounded or the information disseminated to the appropriate authorities.

 

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Signature Date

 

 


REQUEST: (Additional Fee)


ENCLOSED:




FOR OFFICE USE ONLY: