| Title:
|
|
| Given names:
|
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| Surname:
|
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| Address:
|
|
|
|
|
| Telephone:
|
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| Email:
|
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| Test date registered for:
| / /
|
| Request is for (tick one box):
| Refund Test Date Transfer
|
| Centre name/number:
|
|
| Preferred new test date:
| / /
|
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:
| / /
|
| Received by:
| Date:
| / /
|

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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|
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|
|
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|
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| Request (please circle)
| APPROVED
| NOT APPROVED
|
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| Authorised by:
| Date:
| / /
|
| | | | | | |
(IELTS Administrator)