08/21/2023
Josef Silny & Associates, Inc.
Mail applications to: International Education Consultants
7101 SW 102 Avenue
Miami, FL 33173
OR EMAIL TO:
payment@jsilny.org
Tel.: (305) 273-1616
Fax. (305) 273-1338/Translation Fax: (305) 273-1984
E-Mail: info@jsilny.org
Web Site: www.jsilny.org
Application for Evaluation of Foreign Educational Credentials
for Boards of Nursing
Information on Josef Silny and Associates, Inc., International Education Consultants (JS&A)
JS
&A is an organization of highly qualified international education consultants. Mr. Silny is recognized nationally and internationally as an
expert in the field of foreign credential evaluations and international admissions. He has been the Director of International Admissions at the
University of Miami and the City University of New York. He has participated as a panelist or workshop director at national professional
conferences annually since 1974. He has held numerous committee chairmanships and memberships in national professional organizations
and corporations. Mr. Silny has published a book and numerous articles in the field of international education. All international education
consultants associated with Mr. Silny are highly qualified in the field of foreign credential evaluations. JS&A is a member of the National
Association of Credential Evaluation Services, Inc. (NACES)
AP
PLICATION PROCEDURES - Please be sure to read the complete information on our website at www.jsilny.org
.
PLEASE BE AWARE THAT WE WILL NOT PROCESS YOUR REQUEST FOR ANY SERVICE UNLESS WE RECEIVE YOUR FILLED-OUT AND
SIGNED APPLICATION AND CORRESPONDING FEES. JS&A WILL NOT BE RESPONSIBLE FOR DOCUMENTS SENT TO US.
IF ACADEMIC
CREDENTIALS ARE SENT TO US FROM ISSUING INSTITUTIONS, BE SURE THAT WE RECEIVE YOUR FILLED OUT APPLICATION WITH
PAYMENT FIRST. IT IS THE APPLICANT’S RESPONSIBILITY TO SUBMIT THE DOCUMENTS WHICH NEED TO BE EVALUATED.
In or
der to receive an evaluation, an applicant must provide the following:
1. A completed Application for Evaluation of Foreign Educational Credentials signed by the applicant
2. A non-refundable evaluation fee in U.S. dollars. Make the bank check or money order payable to Josef Silny & Associates, Inc. (We
cannot accept postal money orders or payments through Western Union). If you are paying by a credit card you must fill out the Credit
Card Information form. All evaluation fees, including fees for rush report, grade point average equivalent, extra copies, and translation
are NON-REFUNDABLE.
3. EDUCATIONAL DOCUMENTS:
a) Official diplomas and certificates in the original language
b) Official transcripts in the original language (names of courses, grades, and hours of instruction) for every year of study
c) A Syllabus of university studies (description of each course or subject studied) is required
4. TRANSLATIONS: Documents in a language other than English must be accompanied by professional, certified English translations.
Translations supplement, but do not replace the original documents. JS&A offers professional certified translations. JS&A is a
Corporate Member of the American Translators Association. For further information on the JS&A Translation Service, call 305-273-
1616 or e-mail or fax your request for translation estimate along with all pertinent documents.
E-mail: translation@jsilny.org Translation fax: 305-273-1984
Processing Information: For nursing licensure: transcript, degree, course descriptions, and filled out charts must be sent by the issuing
institution(s) directly to JS&A and will be verified. In addition, we need to receive directly from the issuing authority, applicant’s nursing
license, date issued, date of expiration and if the applicant’s license was ever revoked or suspended. Academic credentials received directly
from foreign institutions are considered confidential and cannot be given to applicants. The documents you submit with your application,
with the exception of any originals, will become the property of Josef Silny & Associates, Inc. and they will not be returned. When it has
been determined that documents submitted for evaluation or translation were forged or altered in any way, no evaluation report or translation
will be prepared and the fees will not be refunded. All recipients indicated on the application form will be notified. If the application is not
completed within one year, JS&A will close the file. A new evaluation fee will be required for updating the file. JS&A will keep
applications with academic credentials for one year only. Please note that all fees are subject to change without notice. Refusal of service:
JS&A reserves the right to refuse service to anyone. In preparing an evaluation report, every effort is made to consult appropriate resources,
in order to provide the most accurate evaluation possible. JS&A will provide a list of the references used in making the specific evaluation
upon written request. JS&A does not discriminate among applicants as to the age, sex, race, religion, national origin, disability, or marital
status.
Company Contact
Information
Website Link
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8/21/2023
PROCESSI
NG TIME
1. Standard Processing Time: Evaluations are normally prepared in at least 20 working days from the receipt of all required fees,
information, documentation and verifications. Evaluations which require extensive research and correspondence may take longer to prepare.
2. Rush Evaluation Reports
10-Working Days Evaluation Report
Rush e
valuation reports will be completed in a timely fashion, upon receipt of all required fees, information and documentation. If, for any reason,
the evaluation report cannot be completed within the specified time after receipt of all required fees, information and documentation, the rush fee
will be refunded and the evaluation will be completed as quickly as possible. The rush fee will be adjusted to reflect the actual processing time and a
refund of the difference will be issued. Rush evaluation reports must be paid for by bank check, money order or credit card.
COST OF EVALUATIONS
1. Nursing Course-by-Course – U.S. $400 (Licensure only). The cost for each additional state board is $400
2. 10-Working Days Evaluation Report - U.S. $100 in addition to the basic fee
3. Re-evaluation - Re-evaluations based on documents not submitted with the original request are considered new evaluations and a second
payment of the basic fee $400 is required.
4. Change of state board of nursing - If the academic credentials have not been received, the fee is U.S. $100. Once the academic credentials
have been received, the fee is U.S. $400.
5. Extra evaluation reports - Additional original evaluation reports requested at the time of evaluation cost $20 each. Each evaluation report
requested after the evaluation has been completed costs $30 (evaluations may be available only within 3 years of the original date of issuance).
Please add $5 to the cost of each report that you wish to be mailed to you in a specially sealed JS&A envelope.
6. The applicants are responsible for any verification fees charged by their universities.
7. Do not send us any of your original academic credentials. If you do, you will be responsible for payment for their safe return (U.S. $45 for a
courier in the United States and U.S. $85 for a courier to other countries).
INFORMATION ABOUT EVALUATIONS
Sending your eval
uation - Your evaluation will be sent electronically to the State Board of Nursing you specified in this application. If you would
like to send your evaluation to yourself or anyone else, select an extra evaluation report service and list the name and address in this application.
Method of Operation - To keep the cost of evaluations as low as possible, the evaluation service is conducted by mail. If there are questions
concerning an application, Josef Silny & Associates, Inc. will e-mail, write, or telephone the applicant. If the applicant requests a personal
interview, the charge will be U.S. $100 per half hour. Interviews are by appointment only.
Reassessment of Education Systems - Evaluations are based upon the best information and resources currently available to foreign credential
evaluators in the United States. Josef Silny & Associates, Inc. reserves the right to reassess educational systems as new and additional information
becomes available.
Satisfaction with Evaluations - JS&A generally follows the Placement Recommendations of The National Council on the Evaluation of Foreign
Educational Credentials. JS&A guarantees that all evaluations are prepared by highly qualified evaluators, but it cannot guarantee that the applicant
will agree with the evaluation. Any questions or concerns about evaluations must be submitted in writing.
08/21/2023
PERSONAL INFORMATION
Gender:
Male Female
Full name:
Last name Given name Middle name/Maiden name
Street Address: Apartment #
(if applicable)
City State Zip code Country (if not U.S.)
Date of birth: Country of citizenship: Country of birth:
Month / Day / Year
Tele
phone: Fax: E-mail:
Area code and number Area code and number
Type of Professional Service Requested:
Evaluation Basic Fee
Licensing: Nursing (U.S. $400 basic fee)
Rush Fee
10-Day Rush Evaluation (U.S. $100 + basic fee)
Additional Services
Extra Evaluation Report (U.S. $20 per report) How many?
Extra Report in Sealed Envelope (U.S. $25 per report) How many?
Secure Return of Originals U.S. $
Translation (quote provided upon request) U.S. $
Other U.S. $
Please indicate for which State Board of Nursing this evaluation has been requested for:
From whom did you learn of Josef Silny & Associates, Inc.:
Have
you used JS&A services previously? Translation: No: Yes: Date:
Evaluation: No: Yes: Date:
Your evaluation report will be sent electronically to the State Board of Nursing you specified and to you.
If you want your evaluation to be sent to an agency or employer (at U.S. $20/report), please list their names and addresses OR email below.
If requesting more than 2 reports, please attach a sheet with additional addresses. Please specify method of delivery per address in the U.S.
(first address): electronically ($0) courier ($45) Priority Mail ($20) (second address): electronically ($0) courier ($45) Priority Mail ($20)
1. 2.
ACADE
MIC HISTORY
Educational Institutions Attended (You must list all educational institutions you have attended. Begin with the first year of elementary school and include
any school you are now attending.)
I, the undersigned applicant, certify and represent that all information provided in this Application is complete, factually accurate, and honestly presented, and that I
have read and understand the instructions and conditions (including that all fees are non-refundable). I agree to the terms stated herein. I understand that the
evaluation is advisory and is not binding upon any agency or institution that uses it. Further, in consideration of the payment by the undersigned applicant, and the
mutual undertakings by the parties as stated in this Application ("Agreement"), the undersigned applicant releases JS&A, its officers, directors, employees, and
agents, from any liability or damages resulting from: (a) the use to which I or any agency or institution puts the evaluation, and (b) for the loss of any original
documents. In addition, any litigation arising out of this Agreement will be under Florida law, and venue will be in Miami-Dade County, Florida. The prevailing
party to any litigation arising out of this Agreement is entitled to reasonable attorney's fees and all costs accrued during the litigation.
Signature of
the applicant: Date:
Name of Institution
City, Country
Attendance
From - To
Diplomas or Certificates
Year of
Graduation
1.
2.
3.
4.
5.
6.
-
-
-
-
-
-
Application must be signed by hand or digital signature (not typed).
By signing you agree to all terms on this agreement.
ORGANIZATIONS
WHI
CH ACCEPT E
VAL
UATI
ONS D
O
N
E B
Y
JS&A
JS&A is a Me
mbe
r
of t
h
e National A
ssoci
at
ion o
f
Cre
de
nt
ial Evaluation Services,
Inc. (NACES). Evaluations prepared by JS&A are
accepted and recognized by the organizations listed below:
1.
U.S. Federal Government
USCIS -The United States Citizenship and Immigration Services
The United States Department of Agriculture
The United States Department of Defense
The United States Labor Department
The United States Office of Personnel Management
Federal Bureau of Prisons
Health Care Financing Administration
2.
U.S. Armed Forces
Air Force
Army
Marines
3.
Licensing Boards
Accounting: Arkansas, California, Colorado, Connecticut, Florida, Indiana, Kentucky, Michigan, New Mexico, Ohio,
Pennsylvania, South Dakota, Tennessee, Virginia
Architecture: Alaska, California
Barbers: Florida, Minnesota, South Dakota
Cosmetology: Georgia, Louisiana, Minnesota, North Carolina, South Carolina, Tennessee, Utah, Vermont
Engineering: Alaska, Florida, Louisiana, Maryland, New Jersey, Puerto Rico, Texas, Virginia
Law: California, Florida, Texas
Marriage and Family Therapy, Mental Health: Florida
Massage Therapy: California, Florida, Michigan, Nevada, Utah, Virginia
Medical Laboratory: American Medical Technologists, American Society of Clinical Pathologists, Health Care Financing
Administration, California, Connecticut, Florida, Georgia, Nevada, North Dakota, Tennessee
Nursing: Alabama, Arizona, Arkansas, California (vocational nursing only), Colorado, District of Columbia, Florida, Hawaii, Idaho,
Illinois, Indiana, Kentucky, Louisiana, Michigan, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North
Dakota, Oklahoma, Oregon, Pennsylvania, Puerto Rico, South Carolina, Texas, Utah, Vermont, Virginia, Washington, Wyoming
Opticianry: Florida
Psychology: California, Delaware, District of Columbia, Florida, Maryland, Ohio, Oregon, Virginia
Respiratory Care: National Board for Respiratory Care, California, Florida
Social Work: Florida
Speech-Language Pathology and Audiology: American Speech-Language-Hearing Association, Florida, Georgia
Texas Medical and Dental Schools Application Service
4.
State Departments of Education
Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Illinois,
Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nebraska,
Nevada, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode
Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington,
West Virginia, Wisconsin, Wyoming
5.
Other Governmental and Private Agencies
American Association for Clinical Chemistry
Association of Colleges of Osteopathic Medicine
American Association of Colleges of Podiatric Medicine
Association of American Veterinary Medical Colleges
Broward County Sheriff’s Office
CASPA - Central Application Service for Physician Assistants
Florida Department of Health and Rehabilitative Services
National Career Development Association
NCAA
Office of Personnel of: City of Miami, Ft. Lauderdale, Miami Beach, New York City, State of New York
6.
Hundreds of Colleges and Universities
Many other organizations which do not appear on this list may also accept evaluations done by JS&A. Applicants are advised to check
with the agency, institution, or organization to which they intend to submit the evaluation to make certain that the evaluation will be
recognized.
Page 1
For all state boards of nursing except for Alabama, Louisiana and Virginia Boards of Nursing
Attachme
nt of Nursing Theory and Clinical Clock Hours and Required Coursework
(TO BE COMPLETED BY CLIENT’S INSTITUTION ONLY)
Client’s Name:
Institution:
Address:
Date of Graduation:
Language of Instruction:
Language of Textbooks:
Language for Clinical Experience:
Applicant’s License/Permit Number:
- Date Issued and Date of Expiration:
Was the nursing license ever revoked or suspended? ______No Yes______ (on what date?) ___________
(Please note if this information is not available or does not exist)
Nursing Education Categories
Theory Clock
Hours
Clinical Clock
Hours
List course in which these topics are
integrated:
Medical:
Surgical:
Obstetric:
Pediatric:
Psychiatric / Mental Health:
Geriatric:
Total number of Theory Clock hours completed: hrs.
Total number of Clinical Clock hours completed: hrs.
PLEASE INCLUDE COURSE DESCRIPTIONS, INCLUDING HOURS OF INSTRUCTION
(THEORY AND CLINICAL) OF ALL SUBJECTS LISTED IN THIS CHART.
08/21/2023
Page 2
Please provide us with your name, title, signature and institutional seal for our records.
Name
Title
Stamp:
Date:
The institution MUST send the completed
charts along with the official student’s graduation diploma(s),
transcripts and course descriptions DIRECTLY to:
Josef Silny & Associates, Inc.
In
ternational Education Consultants
7101 SW 102 Avenue,
Miami, FL 33173
USA
08/21/2023
Page 1
For ALABAMA BOARD OF NURSING
Attachment of Nursing Theory and Clinical Clock Hours and Required Coursework
(TO BE COMPLETED BY CLIENT’S INSTITUTION ONLY)
Client’s Name:
Institution:
Address:
Date of Graduation:
Language of Instruction:
Language of Textbooks:
Language for Clinical Experience:
Applicant’s License/Permit Number:
- Date Issued and Date of Expiration:
Was the nursing license ever revoked or suspended? ______No Yes______ (on what date?) ___________
(Please note if this information is not available or does not exist)
Nursing Education
Categories
Theory Clock
Hours
Clinical Clock
Hours
List course in which these topics are
integrated:
Adult Medical:
Adult Surgical:
Maternal/Infant
Nursing Care of
Children:
Psychiatric / Mental
Health:
PLEASE INCLUDE COURSE DESCRIPTIONS, INCLUDING HOURS OF INSTRUCTION
(THEORY AND CLINICAL) OF ALL SUBJECTS LISTED IN THIS CHART.
Official original high school credential must also be submitted. If the high school credentials were not issued in
English a certified English translation must also be submitted.
If nursing courses and textbooks were not taught in English, provide proof of passage of an English Proficiency Exam.
The Board accepts the following:
o IELTS Academic – computer- or paper-based
o TOEFL iBT produced by Educational Testing Service (ETS)
o PTE Academic
o MELAB produced by Cambridge Michigan Language Assessments (CaMLA)
08/21/2023
Page 2
Please provide us with your name, title, signature and institutional seal for our records.
Name
Title
Stamp:
Date:
The institution MUST send the completed charts along with the official student’s graduation diploma(s),
transcripts and course descriptions DIRECTLY to:
Josef Silny & Associates, Inc.
International Education Consultants
7101 SW 102 Avenue,
Miami, FL 33173
USA
08/21/2023
Page 1
For Louisiana State Board of Nursing
Attachment of Nursing Theory and Clinical Clock Hours and Required Coursework
(TO BE COMPLETED BY CLIENT’S INSTITUTION ONLY)
Client’s Name:
Institution:
Address:
Date of Graduation:
Language of Instruction:
Language of Textbooks:
Applicant’s License/Permit Number:
- Date Issued and Date of Expiration:
Was the nursing license ever revoked or suspended? ______No Yes______ (on what date?) _________
Is there any record of disciplinary action? ______No Yes ______(on what date?) ___________
(Please note if this information is not available or does not exist)
Nursing Education Categories
Theory Clock
Hours
Clinical Clock
Hours
List course in which these topics are
integrated:
Medical:
Surgical:
Obstetric:
Pediatric:
Psychiatric / Mental Health:
Total number of Theory Clock hours completed: hrs.
Total number of Clinical Clock hours completed: hrs.
PLEASE INCLUDE COURSE DESCRIPTIONS, INCLUDING HOURS OF INSTRUCTION
(THEORY AND CLINICAL) OF ALL SUBJECTS LISTED IN THIS CHART.
08/21/2023
Page 2
CLINICAL TRAINING EXPERIENCE:
COMPLETED
List courses in which these topics
are integrated:
YES NO
Clinical Training - Acute Care:
{Care of critically ill patients: intensive care units (ICUs): pediatric
ICUs, neonatal ICUs, cardiac care units, cardiac catheter labs,
telemetry units, progressive care units, emergency departments,
and recovery rooms, home healthcare, managed care organizations,
outpatient surgery centers, clinics, and flight units…} *
Clinical Training – Long-term Care:
(Patient assessment; care planning; managing clinical emergencies;
safe medication administration; ethical issues; residents’ rights;
infection control; integrative care…) *
Clinical Training – Community Health Settings:
(Identification of common health problems in the community while
treating patients and creation of intervention plans to correct or
prevent the health and safety issues) *
Please provide us with your name, title, signature and institutional seal for our records.
Name
Title
Stamp:
Date:
The institution MUST send the completed charts along with the official student’s graduation
diploma(s), transcripts and course descriptions DIRECTLY to:
Josef Silny & Associates, Inc.
International Education Consultants
7101 SW 102 Avenue,
Miami, FL 33173
USA
08/21/2023
08/21/2023
Page 1
For Virginia Board of Nursing
Attachment of Nursing Theory and Clinical Clock Hours and Required Coursework
(TO BE COMPLETED BY CLIENT’S INST
ITUTION ONLY)
Client’s Name:
Institution:
Address:
Date of Graduation:
Language of Instruction:
Language of Textbo
oks:
Language for Clinical Experience:
Applicant’s License/Permit Number:
- Date Issued and Date of Expiration:
Was the nursing license ever revoked or suspended? ______No Yes______ (on what date?) ___________
(Please note if this information is not available or does not exist)
Nursing Education
Categories
Theory
Clock
Hours
Clinical
Clock
Hours
List course in which these topics
are integrated:
Medical:
Surgical:
Obstetric:
Pediatric:
Psychiatric / Mental
Health:
Geriatric:
Total number of Theory Clock hours completed: hrs.
Total number of Clinical Clock hours completed: hrs.
We must receive the official results from one of these tests: TOEFL, TOEIC or IELTS.
PLEASE INCLUDE COURSE DESCRIPTIONS, INCLUDING HOURS OF INSTRUCTION
(THEORY AND CLINICAL) OF ALL SUBJECTS LISTED IN THIS CHART.
08/21/2023
Page 2
Please provide us with your name, title, signature and institutional seal for our records.
Name
Title
Stamp:
Date:
The i
nstitution MUST send the completed charts along with the official student’s graduation diploma(s), transcripts and
course descriptions DIRECTLY to:
Josef Sil
ny & Associates, Inc.
International Education Consultants
7101 SW 102 Avenue,
Miami, FL 33173
USA
EXCLUSIVELY FOR THE FLORIDA BOARD OF NURSING
APPLICANT’S NAME:
UNIT OF STUDY:
COMPLETED
List courses in which these topics
are integrated:
YES
NO
THEORETICAL AND CLINICAL INSTRUCTION
Personal, Family and Community Health Concepts:
(Parent-Child Courses, Pediatrics Courses, Community Health, Public
Health, Home Health, Health Promotion) *
Nutrition:
Human Growth and Development Throughout the Life
Span:
(Child Psychology, Psychology of Human Development, Developmental
Psychology) *
Body Structure and Function:
(Anatomy, Physiology, Physiopathology) *
Interpersonal Relationship Skills:
(Introduction to Health Communication, Interpersonal Communication,
Psychiatric Mental Health, Health History Assessment) *
Mental Health Concepts:
(Psychiatric Nursing, Mental Health Nursing, Psychology and Mental
Health)*
Pharmacology and Administration of Medications
Legal Aspects of Practice:
(Professional Issues Courses, Legal Issues and Trends, Legal Issues and
Ethics, Practice and Ethics, Leadership)*
Interpersonal Relationships and Leadership Skills:
(Leadership and Management) *
This category is required ONLY for professional or registered nurses.
This content is not required for practical nurses.
08/21/2023
08/21/2023
UNIT OF STUDY:
COMPLETED
List courses in which these topics
are integrated:
YES
NO
Professional Role and Function:
(Professional Issues in Nursing, Issues and Trends in Nursing)*
This category is required ONLY for professional or registered nurses.
This content is not required for practical nurses.
Health Teaching and Counseling Skills:
(Nursing Assessment, Nursing Process and/or Health Promotion) *
This category is required ONLY for professional or registered nurses.
This content is not required for practical nurses.
CLINICAL TRAINING EXPERIENCE
Clinical Training - Acute Care:
{Care of critically ill patients: intensive care units (ICUs): pediatric ICUs,
neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units,
progressive care units, emergency departments, and recovery rooms, home
healthcare, managed care organizations, outpatient surgery centers, clinics,
and flight units…} *
Clinical Training – Long-term Care:
(Patient assessment; care planning; managing clinical emergencies; safe
medication administration; ethical issues; residents’ rights; infection
control; integrative care…) *
Clinical Training – Community Health Settings:
(Identification of common health problems in the community while treating
patients and creation of intervention plans to correct or prevent the health
and safety issues) *
* Denotes course names which may pert
ain to the respective unit of study. However, this is not an all-inclusive list of courses
which may apply.
Please provide us with your name, title, signature and institutional seal for our records.
Name
Title
Stamp:
Date:
The institution MUST send the completed charts along with the official student’s graduation diploma(s),
transcripts and course descriptions DIRECTLY to:
Josef Silny & Associates, Inc.
International Education Consultants
7101 SW 102 Avenue,
Miami, FL 33173
USA
REQUEST FOR NURSING LICENSE
Foreign licensing board must complete all fields in this form. If this document is completed in a
language other than English, it must be accompanied by a certified English translation.
This form must be submitted directly by mail to: Josef Silny and Associates, Inc.
International Education Consultants
7101 SW 102 Ave
Miami, FL 33173 - USA
Or electronically to the email address of your evaluator which can be found under CONTACT US.
A r
Yes/No
Yeso
Yes/No
Yes/No
08/21/2023
08/21/2023
Josef Silny & Associates, Inc.
International Education Consultants
Tel.: (305) 273-1616
Fax: (305) 273-1338 / Translation Fax: (305) 273-1984
E-Mail: [email protected]
Website: www.jsilny.org
CREDIT CARD INFORMATION
You must include the credit card holder’s copies of the front and back of the credit card and U.S. Driver’s
License OR Foreign Passport.
Name of Cardholder:
As it appears on the credit card
First Middle Last
E-mail address: _________________________________________ Phone No.: _________________________________________
Area code and number
Name of Applicant:
If different from the cardholder
First Middle Last
Billing Address:
Street address Apartment number (if applicable)
City State Zip code Country (if not U.S.)
I authorize Josef Silny & Associates, Inc. to charge my (check one):
VISA MASTER CARD DISCOVER
in the TOTAL amount of U.S. $
(TOTAL amount of your order must be filled in to process your payment.)
CREDIT CARD NUMBER:
3-digit security code on back of card:
Expiration Date (month/year):
Signature of Cardholder (Required): Date:
This signature authorizes Josef Silny & Associates, Inc. (JS&A) to charge the amount for the requested services in U.S.
dollars and the cardholder agrees to be bound by all Terms and Conditions (including that all fees are non-refundable)
as stated in the JS&A application.
