PR O U D C O - O WNER O F I ELT S
Request for Refund or Test Date Transfer Form
PERSONAL DETAILS
TITLE:
GIVEN NAMES: Thanh Binh
FAMILY NAME:
ADDRESS:
NATIONAL ID/ PASSPORT No
TELEPHONE: 091 1916996 EMAIL:
CHANGE REQUESTED:
Request is for (đánh dấu chọn): □ REFUND □ TEST DATE TRANSFER
CENTRE NAME / NUMBER:
TEST DATE REGISTERED FOR:
MODULE REGISTERED FOR: □ ACADEMIC □ GENERAL TRAINING
Please select the test that you registered for:
□ IELTS (Paper Based) □ Computer-delivered IELTS □ IELTS for UKVI (Paper Based)
□ IELTS for UKVI (Computer-delivered) □ IELTS Life Skills □ OSR (Computer-delivered)
PREFERRED NEW TEST DATE:
PREFERRED NEW MODULE: □ ACADEMIC □ GENERAL TRAINING
Please select the test that you wish to transfer to:
□ IELTS (Paper Based) □ Computer-delivered IELTS □ IELTS for UKVI (Paper Based)
□ IELTS for UKVI (Computer-delivered) □ IELTS Life Skills □ OSR (Computer-delivered)
TEST TAKER STATEMENT
Please detail your reasons for applying for a refund or a test date transfer.
In case of medical reasons, this form must be accompanied by an original medical certificate. For other reasons, please attach relevant
documentation/evidence (police report, military service notice, death notice). Attach an extra sheet if there is insufficient space.
TEST TAKER SIGNATURE: DATE: / /
RECEIVED BY: DATE: / /
TEST CENTRE USE ONLY:
Request (please select): □ APPROVED □ NOT APPROVED
AUTHORISED BY:
(IELTS ADMINISTRATOR) DATE / /
