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Request for License / Registration / Diploma

Order # 2685671
CGFNS International, Inc. • 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA • (215) 222-8454 • www.cgfns.org
Applicant: * Please sign / date and send this form to your Licensing or School Authority to complete the remaining information.
Applicant's Current Name: Elisa Iulia Daniliuc
Name when License / Registration /
Daniliuc Elisa Iulia
Diploma was Issued (If Different):
Other Names: Popescu
Professional Title: Registered Nurse Country: Romania
License / Registration / Diploma
B034083 Birth Date: April 13, 1981
Number:
Email: elisa.daniliuc@gmail.com Telephone: (0114) 0758060644
Mailing Address: Graurului,nr 17
bl C7, ap 29
Brasov,Brasov 500376-ROMANIA

* Applicant's Signature: *Date:

(Month-Day-Year)
To License / Registration Official:
1. Complete all the questions on this form.
2. Attach a copy of the applicant's professional registration/license/certification documents issued in its original language, accompanied
by a certified English translation (if not in English).
3. Place this form and the documents listed above in an envelope, close the envelope and place your seal or stamp over the flap.
4. Send via airmail (preferably trackable) to:
CGFNS International, 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA.
For questions, please contact CGFNS International at +1 (215) 222-8454 Monday through Friday from 10 a.m. to 3 p.m. (EST)
Applicant's Birth Date:
Applicant's Name When License / Registration was issued: Month Day Year

License / Registration Number:

Legal Title of License / Registration:

Current License / Registration Address: Street Address P.O. Box (Optional)

Current License / Registration Address: City State / Province Postal Code Country

Current License / Registration Telephone: Current License / Registration Web Address:

Current License / Registration Registrar Contact Email: Current License / Registration Registrar Fax:

THIS FORM IS VALID FOR THE BELOW PERSON AND REGULATORY AUTHORITY
Elisa Iulia Daniliuc ■ Romania - License Number B034083
Order #: 2685671 ■ March 5, 2018 ■ Rev B: Dec. 2017 ■ Page 1 of 2
© 2017 CGFNS International, Inc. All rights reserved.
Request for License / Registration / Diploma - Order # 2685671
CGFNS International, Inc. • 3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 USA • (215) 222-8454 • www.cgfns.org

License / Registration Official, please complete all questions:

License / Registration – Date Issued: License / Registration – Expiration Date:

Status of License / Registration (Circle One):


*Please attach an explanation if the applicant's license /
Active /
Expired Inactive Restricted* registration / diploma has ever been revoked, suspended, limited,
Current
or placed on probation

Was the Professional School Accredited or Government


Approved When Applicant Completed the Courses or If Yes, Name of Organization Accrediting or Approving
Graduated? (Circle One): Professional School:
Yes No

Date Professional School Accredited or Approved:


Month Day Year

Was the Professional Education Program Accredited or


Government Approved When Applicant Completed the If Yes, Name of Organization Accrediting or Approving the
Courses or Graduated? (Circle One): Professional Education Program:
Yes No

Date Professional Education Program Accredited or


Approved:
Month Day Year

Program Type (Circle One):


Baccalaureate Associate
Diploma Other (specify): _____________________________________
degree Degree

Attendance Dates:
Month Year Month Year
to

I hereby attest that the enclosed registration / license / certification documents for Elisa Iulia Daniliuc, and the additional
information provided on this form are also accurate. Please sign below and then PLACE YOUR SEAL BELOW.

License / Registration Official Signature: Month Day Year

Print Name of License / Registration Official: License / Registration Official Title:

THIS FORM IS VALID FOR THE BELOW PERSON AND REGULATORY AUTHORITY
Elisa Iulia Daniliuc ■ Romania - License Number B034083
Order #: 2685671 ■ March 5, 2018 ■ Rev B: Dec. 2017 ■ Page 2 of 2
© 2017 CGFNS International, Inc. All rights reserved.