Request for License / Registration /
Diploma
Order # 3513027
CGFNS International, Inc. | 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA | +1 (215) 222-8454 | www.cgfns.org
Applicant: *Please sign, date and send this form to your License / Registration / School Authority (if you were licensed by diploma) to
complete the remaining information.
Current Name: TIPSY ANTONY
Name When License / Registration
Was Issued (If Different):
Other Names:
Professional Title: Registered Nurse Country: India - Delhi
License / Registration /
Diploma Number:
48472 Date of Birth: June 5, 1990
Email: [email protected] Telephone: (+91) 9718357088
B-402,NEW KANCHANJUNGA APPT
Mailing Address: PLOT 1,SECTOR 23 ,DWARKA
NEW DELHI,Delhi 110077-INDIA
I, TIPSY ANTONY, hereby give my consent to the License / Registration / School Authority responsible for the profession of
Registered Nurse in India - Delhi to provide CGFNS International, Inc. the requested information and supporting
documents.
Month (Jan, Feb, Mar, …) Day Year
*Applicant Signature: *Date Signed:
Attention: This is a customized form for use only by the applicant and Institution identified below. Do not duplicate this form for
any other applicant or institution.
Questions?: Contact CGFNS International at +1 (215) 222-8454 Monday through Friday from 9:00 am to 12:30 pm (EST).
TIPSY ANTONY | Delhi Nursing Council - Delhi - License Number 48472
Order #:o3513027 | Doc ID #: DL1460095 | August 19, 2022 | Rev E:Jun. 2019 | Page 1 of 3
©2022 CGFNS International, Inc. All rights reserved
Request for License / Registration / Diploma - Order # 3513027
CGFNS International, Inc. | 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA | +1 (215) 222-8454 | www.cgfns.org
To License / Registration / School Official:
1. Complete all areas on this form. All documents must have a certified English translation (if not in English).
2. Attach a copy of the applicant's professional License / Registration / Diploma document that was issued in its original language. If
document is not in English, also include a certified English translation.
3. Place an official License / Registration / School Authority seal / stamp over the flap of the institution's official envelope (marked with a
return address) that contains the completed form and requested documents.
4. Send via postal mail (preferably trackable) to:
CGFNS International, Inc.
3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
USA
Applicant Date of Birth:
Applicant Name When Registered: Month (Jan, Feb, Mar, ...) Day Year
License / Registration / Diploma Number:
Professional Title of License / Registration / Diploma Awarded (ex. Registered Nurse):
Name of the License / Registration / School Authority:
License / Registration / School Authority Current Street Address (P.O. Box, if needed):
City: State / Province: Postal Code: Country:
License / Registration / School Authority Telephone Number: License / Registration / School Authority Web Address (if any):
License / Registration / School Authority Contact Email: License / Registration / School Authority Fax Number (if any):
Method of License / Registration:
National / Provincial / State Exam | If exam, Name of Examination:
☐ _________________________________________________________________________
Endorsement / Review of Another
☐ License ☐ Diploma ☐ Registration
Other (please specify):
☐ _______________________________________________________________________________________________________________
License / Registration / Diploma – Issued Date: License / Registration – Expiration Date: (if does not expire, write "no expiration"):
Month (Jan, Feb, Mar, ...) Day Year Month (Jan, Feb, Mar, ...) Day Year
Attention: This is a customized form for use only by the applicant and Institution identified below. Do not duplicate this form for
any other applicant or institution.
Questions?: Contact CGFNS International at +1 (215) 222-8454 Monday through Friday from 9:00 am to 12:30 pm (EST).
TIPSY ANTONY | Delhi Nursing Council - Delhi - License Number 48472
Order #:o3513027 | Doc ID #: DL1460095 | August 19, 2022 | Rev E:Jun. 2019 | Page 2 of 3
©2022 CGFNS International, Inc. All rights reserved
Request for License / Registration / Diploma - Order # 3513027
CGFNS International, Inc. | 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA | +1 (215) 222-8454 | www.cgfns.org
License / Registration / School Official, please complete all areas of this form:
Status of License / Registration / Diploma (Mark One):
☐ Active / Current ☐ Expired ☐ Inactive ☐ Restricted* ☐ Revoked* ☐ Suspended*
*If your license / registration / diploma was restricted, revoked or suspended, please provide or attach an explanation:
Graduation / Completion Date:
Professional School Name: Month (Jan, Feb, Mar, ..) Year
School Street Address (P.O. Box, if needed):
City: State / Province: Postal Code: Country:
Was this Professional School Accredited or Government Approved When
Student Completed the Courses or Graduated? If Yes, Name of Organization that Accredited or Approved this Professional School:
(Mark only one): ☐ Yes ☐ No
If Yes, Date Professional School Accredited or Approved:
Month (Jan, Feb, Mar, ....) Day Year
Was this Professional Education Program Accredited or Government
Approved When Student Completed the Courses or Graduated? If Yes, Name of Organization that Accredited or Approved this Professional Education Program:
(Mark only one): ☐ Yes ☐ No
If Yes, Date Professional Education Program Accredited or Approved:
Month (Jan, Feb, Mar, ....) Day Year
I (an authorized official) hereby attest that the information provided on this form is accurate and all License / Registration / Diploma
documents enclosed pertains to TIPSY ANTONY. Please sign, print name, date and PLACE OFFICAL SEAL / STAMP BELOW (without a
signature, printed name, title, date signed and official seal / stamp these documents will not be accepted).
License / Registration / School Official Signature: Month (Jan, Feb, Mar, ...) Day Year
_________________________________________________________
Print Name of License / Registration / School Official: License / Registration / School Official Title:
_________________________________________________________ ______________________________________________________________
Place License / Registration / School Authority's
Seal / Stamp anywhere in this box.
Attention: This is a customized form for use only by the applicant and Institution identified below. Do not duplicate this form for
any other applicant or institution.
Questions?: Contact CGFNS International at +1 (215) 222-8454 Monday through Friday from 9:00 am to 12:30 pm (EST).
TIPSY ANTONY | Delhi Nursing Council - Delhi - License Number 48472
Order #:o3513027 | Doc ID #: DL1460095 | August 19, 2022 | Rev E:Jun. 2019 | Page 3 of 3
©2022 CGFNS International, Inc. All rights reserved
