GLOBAL SERVICES ASSOCIATES, Inc.
2554 Lincoln Boulevard, # 445
Marina del Rey, California, 90291-5082, USA
Telephone & Fax: +1-310-828-5709
e-mail: info@globaleval.org
A Member of the National Association of Credential Evaluation Services, Inc. (NACES)
Application for the Evaluation of International Education
PLEASE PRINT CLEARLY IN DARK INK OR TYPE. Thank you.
Name:  Mr. Ms.
_______________________________________________________________
 
Family/Last/Surname              First/Given Name                Middle Name
Name on Documents:
_________________________________________________________________
Family/Last/Surname              First/Given Name                Middle Name
My Mailing Address:
________________________________________________________________
_________________________________________________________________________________
Telephone:  Day: ________________ Night: ________________ Fax: _________________________
                             Area Code     Number                   Area Code     Number              Area Code     Number
Date of Birth: ____/____/____  Gender: Male Female  E-mail: ________________________
                         Month   Day   Year
Country of birth: _______________  Date evaluation is needed: ___________________________
Who told you about GSA? ____________Have you applied to GSA before?_________________
Purpose of Evaluation:  Education Employment Immigration Other: _________________
THE FOLLOWING SECTION MUST BE COMPLETED IN FULL IN ORDER TO COMPLETE YOUR EVALUATION
PLEASE PRINT CLEARLY IN DARK INK OR TYPE starting with your first year in school. Use extra sheets, if necessary, and explain any gaps in your educational history. Thank you. 
Elementary School Name(s)/City/Country Dates Attended

______ to ______
Mo/Yr  Mo/Yr		 Degree/Diploma* & Date it was Earned
Secondary School Name(s)/City/Country Dates Attended

______ to ______
Mo/Yr  Mo/Yr		 Degree/Diploma* & Date it was Earned
College or University Name(s)/City/Country Dates Attended

______ to ______
Mo/Yr  Mo/Yr		 Degree/Diploma* & Date it was Earned
College or University Name(s)/City/Country Dates Attended

______ to ______
Mo/Yr  Mo/Yr		 Degree/Diploma* & Date it was Earned
Certificate/Professional Qualification/Country Dates Attended

______ to ______
Mo/Yr  Mo/Yr		 Degree/Diploma* & Date it was Earned
*Please indicate the name of the degree/diploma/certificate in your native language, if appropriate (e.g., Sarjana).

GSA's FEES & CONDITIONS
  LEVEL OF EDUCATION EQUIVALENT
STATEMENT		 COURSE-BY-COURSE
ANALYSIS
A.
B.
C.
D.

E.
F.
G.
H.
I.
J.
K. 		Elementary/Secondary School
Undergraduate Study (1 to 2 years)
Bachelor's Degree (3 or more years)
Master's Degree (includes Bachelor's) and/or Professional Qualifications/Certificates
Doctorate (E.D., Ph.D., etc.)
Extra Original Evaluations ($15.00 each)
Express Mail/FedEx® to me (US only)
Express Mail//FedEx® to recipient (US only)
Certified Mail (US only)
Rush Fee (3 days - Money Orders only)
Total (Please circle the appropriate amounts above, total, and make money order or check, drawn on a USA Bank ONLY, payable to GSA)
 $45.00     
70.00     
80.00     

100.00     
150.00     
__.00     
20.00/30.00     
20.00/30.00     
10.00     
75.00     

$_______    

 $70.00        
125.00        
150.00        

175.00        
250.00        
__.00        
20.00/30.00        
20.00/30.00        
10.00        
75.00        

$________       

L.

Please send a stamped original evaluation to me and the following recipient by date:__________

___________________________________________________________________________________

___________________________________________________________________________________
M.

Evaluation Conditions: Global Services Associates (GSA) will only provide its services under the following conditions:
• This Application for the Evaluation of International Education contains complete and accurate information provided by the applicant or his/her agent.
• The applicant agrees that GSA is not liable for use or non-use of this evaluation by a third party, third party deadlines, acts undertaken and/or omissions allowed by GSA; all costs and legal expenses will be borne by the applicant should any claim arise regarding this evaluation; GSA is not liable for any consequential damages if the equivalency anticipated by the applicant is not recommended by GSA. GSA also states that all evaluations are advisory in nature, and are NOT binding upon any agency, institution, organization or other third party which may use them.
• GSA reserves the right to refuse to evaluate any documents for any reason whatsoever; nor is it responsible for loss of documents. Any documents which appear to be tampered with, forged, falsified or altered in any way will not be evaluated, resulting in the application being cancelled with no refund of fees. (Fees are only refunded for overpayment.) Also, the intended recipient(s) of the evaluation and other members of the National Association of Credential Evaluation Services, Inc. (NACES) will be notified.
• All photocopies and applications become the property of GSA, and they will not be returned.
• All fees are payable in advance; an application is valid for 4 months. Failure by the applicant to supply any additional requested documentation within 4 months will result in the cancellation of the application with no refund. Disclosure of additional documents by the applicant after the initial evaluation is completed will result in a new application and fees.
• I authorize GSA to contact the institution(s) I attend, as necessary.
N.

As the applicant or the applicant's authorized agent, I have read GSA's brochure and the above statements, and, by signing below, I agree to the conditions stated.
                                                                                                                           /         /200   
Please Check:   Applicant's Signature or  Authorized Agent's Signature         Date     
FOR OFFICE USE ONLY: Amount Paid $ ___________ Date _________   Revised 12/2007
All fees and conditions are subject to revision by GSA without notice