Title:
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Given names:
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Surname:
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Address:
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Telephone:
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Email:
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Test date registered for:
| / /
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Request is for (tick one box):
| Refund Test Date Transfer
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Centre name/number:
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Preferred new test date:
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Candidate Statement (to be completed by the candidate)
Please detail your grounds for applying for a refund or a test date transfer
(attach extra sheet if there is insufficient space).
Candidate signature:
| Date:
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Received by:
| Date:
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Test centre use only: Previous request for refunds/transfer
Registered test date
| Date of prior application
| Grounds for application
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| Medical
| Personal
| Other
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Request (please circle)
| APPROVED
| NOT APPROVED
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Authorised by:
| Date:
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(IELTS Administrator)