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FACS%
Foreign%Academic%Credentials%Service,%Inc.%
105!West!Vandalia,!Suite!120!
Edwardsville,!IL!62025!!
(T)!!618.656.5291!(F)!!618.656.5292!(E)!facs@aol.com!
% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Office%Use%Only% % %
REQUEST%FOR%ADVISORY%EVALUATION%OF%FOREIGN%CREDENTIALS%
Note:!Please!read,!complete!and!return!this!form!with!your!educational!credentials!and!fee!payment.!!!Please%type%or%print%neatly.!
PERSONAL%INFORMATION%
!!! %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% % % % %%%Check%One%
Name:!______________________________________________________________________!!Mr.!!!!Ms.!!!Mrs.!!
! ! Last/Family! ! ! First/Given! ! ! Middle/Maiden!
Mailing!Address:!_______________________________________________________________________________!
_____________________________________________________________________________________________!
_____________________________________________________________________________________________!
City! ! ! State/Province/Region! ! ! Country! ! ! Zip!Code/Postal!Code!
EUmail!Address:!________________________________________________________________________________!
! Note:%%Please%add%our%eLmail%address%“facs@aol.com”%to%your%address%book%to%avoid%our%messages%being%marked%as%Spam.!!
Telephone:!______________________________________!Fax:!__________________________________________!
Date!of!Birth:!____________________________________!Country!of!Birth:!_______________________________!
! ! ! month/date/year!
Country!(s)!of!Credential:!________________________________________________________________________!
Have!you!ever!applied!to!FACS?!!!!!Yes!!!!!!No!If!yes,!indicate!year:!_____________________________________!
Please!indicate!if!you!are!applying!for:!!!!!Uniform!CPA!Examination!!!!CPA!Certificate/License!!
If!applying!for!CPA!Certificate/License,!please!indicate!the!state!and!year!of!passing!in!full!the!Uniform!CPA!Examination:!__________________!
! ! ! ! ! ! ! ! !!!!!!!!!!!! ! !!!!!!!!!!!!!!!!!!State!! !!!Year!
Indicate!board(s)!of!accountancy!to!which!the!advisory!evaluation!is!to!be!mailed*:!
____________________________________________!!!!!!______________________________________________!
____________________________________________!!!!!!______________________________________________!
*The%state%board(s)%of%accountancy%to%which%the%advisory%evaluation%is%to%be%mailed%is%REQUIRED%to%complete%advisory%evaluation.%
Indicate!amount!of!fees!attached!(see!page!4):!_______________________________________________________!
PROCEDURES%AND%CONDITIONS%
• Each!applicant’s!academic!credentials!will!be!evaluated!to!assess!whether!his!or!her!educational!preparation,!
in!the!opinion!of!FACS,!fulfills!the!education!requirement!to!sit!for!the!Uniform!CPA!Examination!in!the!state!
or! jurisdiction! to! which! the! application! is! being! made.! ! The! board! of! each! state! or! other! jurisdiction! will!
consider!the!FACS!evaluation!as!advisory!and!reserves!the!right!to!make!final!determination!as!to!the!eligibility!
of!the!applicant.!!FACS!reviews!only!the!academic!experience!of!an!applicant!and!does!not!provide!advisory!
recommendations! concerning! the! reciprocity! of! foreign! earned! professional! qualifications! and! work!
experience.!
• A!correct!eUmail!address!must!be!provided!for!eUmail!confirmation!of!receipt!of!application!and!for!contact!if!
additional!information!is!required!to!complete!the!evaluation!process.%
• Any!educational!credential!submitted!after!an!evaluation!has!been!completed!will!require!a!new!evaluation!
and!a!new!fee!payment.!!Requests!to!change!an!evaluation!from!one!board!to!another!board!(for!example,!
Washington!to!Florida)!will!require!a!new!fee!payment!for!a!new!evaluation.!%
• All!information!requested!must!be!provided!within!a!oneUyear!period,!at!which!time!the!evaluation!process!
will!have!to!be!initiated!again.!
• FACS!retains!completed!evaluation!records!for!five!(5)!years!from!the!year!of!evaluation.!!
%
% %
Ashry Ahmed Hamed
Kifah tower - Dammam Khubar Haighway Opisit Chember of commerce
Dammam Eastern Province Saudi Arabia 31472
ahmed.ashry999@gmail.com
+966 54 1145 889 +966 13 8459 501
04/09/1973 Egypt
Egypt
Main State Board of Accountancy
$ 160
! 2!
EDUCATIONAL%PREPARATION%
Report! every! school,! college,! and! university! you! have! attended! or! are! now! attending.! ! Give! exact! dates! of!
attendance.!
Elementary/Primary!Schools!
Name!and!Location!(city,!country)! Date!of!Entrance! Date!of!Leaving! Name!of!Diploma,!Degree,!
or!Certificate!(in!original!
language!and!exact!English!
translation)!
! Month! Year! Month! Year! !
! ! ! ! ! !
! ! ! ! ! !
!
Secondary!Schools!(High!School,!Colegio,!Liceo,!Lycee,!Gymnasium,!etc.)!
! ! ! ! ! !
! ! ! ! ! !
!
Colleges,!Universities,!Higher!Institutes!and!other!universityUlevel!schools!
! ! ! ! ! !
! ! ! ! ! !
! ! ! ! ! !
! ! ! ! ! !
!
Other!PostUsecondary!schools!(such!as!professional!or!vocational)!
! ! ! ! ! !
! ! ! ! ! !
! ! ! ! ! !
! ! ! ! ! !
!
Earned!professional!qualifications!(e.g.,!Chartered!Accountant,!Certified!General!Accountant,!etc.)!
! ! ! ! ! !
! ! ! ! ! !
! ! ! ! ! !
!
!
%
Benha University Sep 1991 May 1992
Ain Shams University 1992 May 1995Sep B.Commerce
! 3!
DOCUMENTS%REQUIRED%
• Educational!credentials!must!include!official!transcripts!of!records!from!all!universities!and!other!institutions!
of! higher! education! attended,! including! those! in! the! United! States.! ! Such! records! must! report! all! courses!
(subjects)! by! title! completed,! grades! earned,! and! degrees,! diplomas,! and! certificates! awarded.! ! In! those!
countries!(e.g.!India,!Pakistan,!United!Kingdom)!where!universities!do!not!issue!course!by!course!transcripts!as!
in!the!United!States,!applicants!must!present!all!official!examination!results!for!each!year!of!study,!including!
the!final!year,!specifying!each!course!(subject)!by!title!taken!and!marks!achieved;!and!certification!of!degree!or!
diploma!awarded.!!The!issuing!institution!must!officially!certify!those!examination!results.!
!
• Applicants!who!have!attended!European!universities!and!other!higher!education!institutions!(for!example,!in!
Germany,!Switzerland,!France,!Netherlands,!Sweden,!Poland,!Russia,!etc.)!must!request!those!institutions!to!
provide! FACS! with! an! official! report! of! all! courses! (subjects)! by! title! completed! toward! the! diploma! that!
includes! the! number! of! instructional/lecture/seminar! hours! offered! weekly! in! each! course! (subject)! during!
each!academic!semester!or!year.!!Official!copies!of!diplomas!earned!and!all!examination!results!in!each!course!
(subject)!must!be!provided.!
!
• Academic!records!from!European!schools!that!participate!in!the!European!Credit!Transfer!and!Accumulation!
System!should!report!ECTS!credits!for!each!course.!!
!
• Applicants!who!have!attended!colleges!or!universities!in!the!People’s!Republic!of!China!must!request!those!
institutions! to! provide! FACS! with! transcripts! of! academic! record! that! reports! the! credit! value! and/or! class!
hours!for!each!course!(subject)!must!be!provided.!!Note,!the!Certificate!of!Graduation!may!not!include!the!full!
title!of!the!degree!earned.!!Please!also!include!the!Certificate!of!Degree,!when!applicable.!!Records!submitted!
in!sealed!envelopes!from!the!issuing!college!or!university!cannot!be!returned!to!the!applicant.!!
!
• Applicants!who!have!received!the!General!Certificate!of!Education!in!Advanced!Level!subjects!or!who!have!
passed! the! Hong! Kong! Advanced! Level! Examination! should! submit! official! copies! of! these! certificates! or!
examination!results!that!report!their!Advanced!level!subjects!by!title.!!
!
• Applicants! who! have! earned! professional! qualifications! in! accounting! in! another! country! should! submit!
relevant! supporting! documents,! including! complete! and! official! examination! results! and! qualifications!
granted.!
!
• FACS!recommends!that!descriptions!of!courses!in!accounting!and!businessUrelated!subjects!be!provided.!!If!
this! documentation! is! not! in! the! English! language,! it! must! be! accompanied! by! an! official! English! language!
translation.!!
!
• Official!English!language!translations!must!accompany!official!copies!of!records!that!are!in!another!language.!!
Official! records! including! diplomas,! in! the! original! language! must! be! submitted! with! the! English! language!
translations.!
!
• FACS! may! request! the! applicant! to! provide! additional! or! other! records! and/or! to! complete! supplemental!
forms!describing!his!or!her!educational!preparation!in!order!to!formulate!an!accurate!advisory!evaluation.!!
FACS!will!also,!when!necessary,!contact!an!institution!in!another!country!or!in!the!United!States!for!further!
information!about!an!applicant’s!credentials!including!verification!of!authenticity.!
!
• In!the!event!that!FACS!determines!that!the!academic!credentials!submitted!for!evaluation!have!in!any!way!
been! altered,! tampered! with,! or! forged,! no! evaluation! will! be! prepared.! ! All! fees! will! be! forfeited! and!
appropriate!notification!will!be!issued.!!
!
! 4!
!
!
SERVICES%AND%FEES%
Fees!must!be!paid!in!advance!and!are!nonUrefundable!once!the!evaluation!process!has!been!initiated.!
1. Evaluation!Fee!
!! $200/each!state!(Arizona,!Colorado,!Connecticut*,!Michigan**,!Nebraska,!Nevada,!!
Oklahoma,!Pennsylvania,!South!Dakota,!Vermont,!and!Wisconsin)!! ! ! $__________!
!! $150/each!state!(Florida,!Kentucky,!Mississippi,!New!Mexico,!North!Carolina,!!
!!! and!North!Dakota,)! ! ! ! ! ! ! ! $__________!
!! $100/each!state!(For!full!list,!please!visit!our!website!–!www.facsusa.com)! ! $__________!
!
*This!is!for!Connecticut!State!Board!of!Accountancy!license!application.!
**This!is!for!Michigan!State!Board!of!Accountancy!license!application.!!
!
OPTIONAL%SERVICES%%
The%above%evaluation%fee%includes%one%copy%of%the%evaluation%report%mailed%to%the%board%of%accountancy%and/or%
board%coordinator,%and%one%unofficial%copy%eLmailed%to%the%applicant’s%eLmail%address%provided.%%Please%note%
that%if%original%documents%are%to%be%returned,%a%mailing%service%must%be%selected.%%
!
2. RUSH!SERVICES!
__________!5!Business!Day!Rush!($150.00)***! ! ! ! ! $__________!
__________!10!Business!Day!Rush!($75.00)***! ! ! ! ! $__________!
!
***Rush%services%begin%upon%receipt%and%approval%of%all%required%documents,%application%forms%and%fee%payments.%%Applications%
requesting%rush%service%are%reviewed%within%48%hours%of%receipt.%Mailing%time%is%not%included%in%rush%services.%%Please%see%mailing%
options%below.%%%
_____________% Please%initial%here%that%you%have%read%the%full%Rush%Service%instructions%on%our%website%–%www.facsusa.com%
3. Official!Copies!(Copy/Copies!will!be!sent!by!first!class!mail!or!airmail!unless!otherwise!indicated.)!
__________!x!$10.00/each!extra!copy!(Official!copies!requested!at!time!of!evaluation)! ! $__________!
!!!!!(number)!!!!!!
! !
4. Mailing!Services!!
!
!! U.S.P.S.!Priority!Mail!(domestic!only)! ! ($10.00/address)!! $__________!
!! UPS!Courier!Delivery!(domestic)! ! ! ($20.00/address)!! $__________!
!! UPS!Courier!Delivery!(international)! ! ($60.00/address)!! $__________!
!
5. Facsimile!Transmission!of!Evaluation!(must!provide!accurate!fax!number)! !
!! __________________________________________!! ($15.00/transmission)! $__________!
! ! ! (Fax!Number)!
TOTAL%FEES% % % % % % % % % $__________!
!
The!above!fee!schedule!is!subject!to!change.!
!
Please!make!check!or!money!order!payable!in!US!funds!to!FACS,!Inc.!!(Note,!payment!from!outside!US!must!be!in!
US!Dollars!and!must!be!issued!from!a!bank!that!has!branches!in!the!US!and!includes!routing!numbers.)!
!
! ! I!certify!that!all!of!the!information!provided!on!this!form!is!accurate!and!complete;!!
! ! and!I!have!read!and!accept!the!procedures!and!conditions!described!on!this!form.!!
!
________________________________________!!!!!!!!!!________________________________________!
! ! Applicant’s!Signature! ! ! ! ! ! Date!
!
Rev.!12/14!
100
60
+966 13 8459 501
160
06/02/2016

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CPA-Application-Form-2015

  • 1. ! FACS% Foreign%Academic%Credentials%Service,%Inc.% 105!West!Vandalia,!Suite!120! Edwardsville,!IL!62025!! (T)!!618.656.5291!(F)!!618.656.5292!(E)!facs@aol.com! % %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Office%Use%Only% % % REQUEST%FOR%ADVISORY%EVALUATION%OF%FOREIGN%CREDENTIALS% Note:!Please!read,!complete!and!return!this!form!with!your!educational!credentials!and!fee!payment.!!!Please%type%or%print%neatly.! PERSONAL%INFORMATION% !!! %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% % % % %%%Check%One% Name:!______________________________________________________________________!!Mr.!!!!Ms.!!!Mrs.!! ! ! Last/Family! ! ! First/Given! ! ! Middle/Maiden! Mailing!Address:!_______________________________________________________________________________! _____________________________________________________________________________________________! _____________________________________________________________________________________________! City! ! ! State/Province/Region! ! ! Country! ! ! Zip!Code/Postal!Code! EUmail!Address:!________________________________________________________________________________! ! Note:%%Please%add%our%eLmail%address%“facs@aol.com”%to%your%address%book%to%avoid%our%messages%being%marked%as%Spam.!! Telephone:!______________________________________!Fax:!__________________________________________! Date!of!Birth:!____________________________________!Country!of!Birth:!_______________________________! ! ! ! month/date/year! Country!(s)!of!Credential:!________________________________________________________________________! Have!you!ever!applied!to!FACS?!!!!!Yes!!!!!!No!If!yes,!indicate!year:!_____________________________________! Please!indicate!if!you!are!applying!for:!!!!!Uniform!CPA!Examination!!!!CPA!Certificate/License!! If!applying!for!CPA!Certificate/License,!please!indicate!the!state!and!year!of!passing!in!full!the!Uniform!CPA!Examination:!__________________! ! ! ! ! ! ! ! ! !!!!!!!!!!!! ! !!!!!!!!!!!!!!!!!!State!! !!!Year! Indicate!board(s)!of!accountancy!to!which!the!advisory!evaluation!is!to!be!mailed*:! ____________________________________________!!!!!!______________________________________________! ____________________________________________!!!!!!______________________________________________! *The%state%board(s)%of%accountancy%to%which%the%advisory%evaluation%is%to%be%mailed%is%REQUIRED%to%complete%advisory%evaluation.% Indicate!amount!of!fees!attached!(see!page!4):!_______________________________________________________! PROCEDURES%AND%CONDITIONS% • Each!applicant’s!academic!credentials!will!be!evaluated!to!assess!whether!his!or!her!educational!preparation,! in!the!opinion!of!FACS,!fulfills!the!education!requirement!to!sit!for!the!Uniform!CPA!Examination!in!the!state! or! jurisdiction! to! which! the! application! is! being! made.! ! The! board! of! each! state! or! other! jurisdiction! will! consider!the!FACS!evaluation!as!advisory!and!reserves!the!right!to!make!final!determination!as!to!the!eligibility! of!the!applicant.!!FACS!reviews!only!the!academic!experience!of!an!applicant!and!does!not!provide!advisory! recommendations! concerning! the! reciprocity! of! foreign! earned! professional! qualifications! and! work! experience.! • A!correct!eUmail!address!must!be!provided!for!eUmail!confirmation!of!receipt!of!application!and!for!contact!if! additional!information!is!required!to!complete!the!evaluation!process.% • Any!educational!credential!submitted!after!an!evaluation!has!been!completed!will!require!a!new!evaluation! and!a!new!fee!payment.!!Requests!to!change!an!evaluation!from!one!board!to!another!board!(for!example,! Washington!to!Florida)!will!require!a!new!fee!payment!for!a!new!evaluation.!% • All!information!requested!must!be!provided!within!a!oneUyear!period,!at!which!time!the!evaluation!process! will!have!to!be!initiated!again.! • FACS!retains!completed!evaluation!records!for!five!(5)!years!from!the!year!of!evaluation.!! % % % Ashry Ahmed Hamed Kifah tower - Dammam Khubar Haighway Opisit Chember of commerce Dammam Eastern Province Saudi Arabia 31472 ahmed.ashry999@gmail.com +966 54 1145 889 +966 13 8459 501 04/09/1973 Egypt Egypt Main State Board of Accountancy $ 160
  • 2. ! 2! EDUCATIONAL%PREPARATION% Report! every! school,! college,! and! university! you! have! attended! or! are! now! attending.! ! Give! exact! dates! of! attendance.! Elementary/Primary!Schools! Name!and!Location!(city,!country)! Date!of!Entrance! Date!of!Leaving! Name!of!Diploma,!Degree,! or!Certificate!(in!original! language!and!exact!English! translation)! ! Month! Year! Month! Year! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Secondary!Schools!(High!School,!Colegio,!Liceo,!Lycee,!Gymnasium,!etc.)! ! ! ! ! ! ! ! ! ! ! ! ! ! Colleges,!Universities,!Higher!Institutes!and!other!universityUlevel!schools! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Other!PostUsecondary!schools!(such!as!professional!or!vocational)! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Earned!professional!qualifications!(e.g.,!Chartered!Accountant,!Certified!General!Accountant,!etc.)! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! % Benha University Sep 1991 May 1992 Ain Shams University 1992 May 1995Sep B.Commerce
  • 3. ! 3! DOCUMENTS%REQUIRED% • Educational!credentials!must!include!official!transcripts!of!records!from!all!universities!and!other!institutions! of! higher! education! attended,! including! those! in! the! United! States.! ! Such! records! must! report! all! courses! (subjects)! by! title! completed,! grades! earned,! and! degrees,! diplomas,! and! certificates! awarded.! ! In! those! countries!(e.g.!India,!Pakistan,!United!Kingdom)!where!universities!do!not!issue!course!by!course!transcripts!as! in!the!United!States,!applicants!must!present!all!official!examination!results!for!each!year!of!study,!including! the!final!year,!specifying!each!course!(subject)!by!title!taken!and!marks!achieved;!and!certification!of!degree!or! diploma!awarded.!!The!issuing!institution!must!officially!certify!those!examination!results.! ! • Applicants!who!have!attended!European!universities!and!other!higher!education!institutions!(for!example,!in! Germany,!Switzerland,!France,!Netherlands,!Sweden,!Poland,!Russia,!etc.)!must!request!those!institutions!to! provide! FACS! with! an! official! report! of! all! courses! (subjects)! by! title! completed! toward! the! diploma! that! includes! the! number! of! instructional/lecture/seminar! hours! offered! weekly! in! each! course! (subject)! during! each!academic!semester!or!year.!!Official!copies!of!diplomas!earned!and!all!examination!results!in!each!course! (subject)!must!be!provided.! ! • Academic!records!from!European!schools!that!participate!in!the!European!Credit!Transfer!and!Accumulation! System!should!report!ECTS!credits!for!each!course.!! ! • Applicants!who!have!attended!colleges!or!universities!in!the!People’s!Republic!of!China!must!request!those! institutions! to! provide! FACS! with! transcripts! of! academic! record! that! reports! the! credit! value! and/or! class! hours!for!each!course!(subject)!must!be!provided.!!Note,!the!Certificate!of!Graduation!may!not!include!the!full! title!of!the!degree!earned.!!Please!also!include!the!Certificate!of!Degree,!when!applicable.!!Records!submitted! in!sealed!envelopes!from!the!issuing!college!or!university!cannot!be!returned!to!the!applicant.!! ! • Applicants!who!have!received!the!General!Certificate!of!Education!in!Advanced!Level!subjects!or!who!have! passed! the! Hong! Kong! Advanced! Level! Examination! should! submit! official! copies! of! these! certificates! or! examination!results!that!report!their!Advanced!level!subjects!by!title.!! ! • Applicants! who! have! earned! professional! qualifications! in! accounting! in! another! country! should! submit! relevant! supporting! documents,! including! complete! and! official! examination! results! and! qualifications! granted.! ! • FACS!recommends!that!descriptions!of!courses!in!accounting!and!businessUrelated!subjects!be!provided.!!If! this! documentation! is! not! in! the! English! language,! it! must! be! accompanied! by! an! official! English! language! translation.!! ! • Official!English!language!translations!must!accompany!official!copies!of!records!that!are!in!another!language.!! Official! records! including! diplomas,! in! the! original! language! must! be! submitted! with! the! English! language! translations.! ! • FACS! may! request! the! applicant! to! provide! additional! or! other! records! and/or! to! complete! supplemental! forms!describing!his!or!her!educational!preparation!in!order!to!formulate!an!accurate!advisory!evaluation.!! FACS!will!also,!when!necessary,!contact!an!institution!in!another!country!or!in!the!United!States!for!further! information!about!an!applicant’s!credentials!including!verification!of!authenticity.! ! • In!the!event!that!FACS!determines!that!the!academic!credentials!submitted!for!evaluation!have!in!any!way! been! altered,! tampered! with,! or! forged,! no! evaluation! will! be! prepared.! ! All! fees! will! be! forfeited! and! appropriate!notification!will!be!issued.!! !
  • 4. ! 4! ! ! SERVICES%AND%FEES% Fees!must!be!paid!in!advance!and!are!nonUrefundable!once!the!evaluation!process!has!been!initiated.! 1. Evaluation!Fee! !! $200/each!state!(Arizona,!Colorado,!Connecticut*,!Michigan**,!Nebraska,!Nevada,!! Oklahoma,!Pennsylvania,!South!Dakota,!Vermont,!and!Wisconsin)!! ! ! $__________! !! $150/each!state!(Florida,!Kentucky,!Mississippi,!New!Mexico,!North!Carolina,!! !!! and!North!Dakota,)! ! ! ! ! ! ! ! $__________! !! $100/each!state!(For!full!list,!please!visit!our!website!–!www.facsusa.com)! ! $__________! ! *This!is!for!Connecticut!State!Board!of!Accountancy!license!application.! **This!is!for!Michigan!State!Board!of!Accountancy!license!application.!! ! OPTIONAL%SERVICES%% The%above%evaluation%fee%includes%one%copy%of%the%evaluation%report%mailed%to%the%board%of%accountancy%and/or% board%coordinator,%and%one%unofficial%copy%eLmailed%to%the%applicant’s%eLmail%address%provided.%%Please%note% that%if%original%documents%are%to%be%returned,%a%mailing%service%must%be%selected.%% ! 2. RUSH!SERVICES! __________!5!Business!Day!Rush!($150.00)***! ! ! ! ! $__________! __________!10!Business!Day!Rush!($75.00)***! ! ! ! ! $__________! ! ***Rush%services%begin%upon%receipt%and%approval%of%all%required%documents,%application%forms%and%fee%payments.%%Applications% requesting%rush%service%are%reviewed%within%48%hours%of%receipt.%Mailing%time%is%not%included%in%rush%services.%%Please%see%mailing% options%below.%%% _____________% Please%initial%here%that%you%have%read%the%full%Rush%Service%instructions%on%our%website%–%www.facsusa.com% 3. Official!Copies!(Copy/Copies!will!be!sent!by!first!class!mail!or!airmail!unless!otherwise!indicated.)! __________!x!$10.00/each!extra!copy!(Official!copies!requested!at!time!of!evaluation)! ! $__________! !!!!!(number)!!!!!! ! ! 4. Mailing!Services!! ! !! U.S.P.S.!Priority!Mail!(domestic!only)! ! ($10.00/address)!! $__________! !! UPS!Courier!Delivery!(domestic)! ! ! ($20.00/address)!! $__________! !! UPS!Courier!Delivery!(international)! ! ($60.00/address)!! $__________! ! 5. Facsimile!Transmission!of!Evaluation!(must!provide!accurate!fax!number)! ! !! __________________________________________!! ($15.00/transmission)! $__________! ! ! ! (Fax!Number)! TOTAL%FEES% % % % % % % % % $__________! ! The!above!fee!schedule!is!subject!to!change.! ! Please!make!check!or!money!order!payable!in!US!funds!to!FACS,!Inc.!!(Note,!payment!from!outside!US!must!be!in! US!Dollars!and!must!be!issued!from!a!bank!that!has!branches!in!the!US!and!includes!routing!numbers.)! ! ! ! I!certify!that!all!of!the!information!provided!on!this!form!is!accurate!and!complete;!! ! ! and!I!have!read!and!accept!the!procedures!and!conditions!described!on!this!form.!! ! ________________________________________!!!!!!!!!!________________________________________! ! ! Applicant’s!Signature! ! ! ! ! ! Date! ! Rev.!12/14! 100 60 +966 13 8459 501 160 06/02/2016