IELTS TEST CANCELLATION FORM

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					                                                                                                       UTS CRICOS PROVIDER CODE 00099F




                                           IELTS TEST CANCELLATION FORM
                                ORIGINAL TEST FEE RECEIPT REQUIRED WITH THIS REQUEST FORM

Today’s Date:                   ___/___/_____

Family Name:                    __________________________________________________________________________________

Given Name:                     __________________________________________________________________________________

Date of Birth:                  _________/___________/__________

Postal Address:                 __________________________________________________________________________________
(Not email Address)

Contact Number:                 __________________________________________________________________________________

E-Mail Address:                 __________________________________________________________________________________

Test Date:                      _____/_____/_____           Module: ACADEMIC or GENERAL TEST (please circle)

Reason for REFUND:              __________________________________________________________________________________

                                __________________________________________________________________________________


Account Details: EFTPOS (Direct Refund) OR CHEQUE (please circle))


If you do not have your Bank Card with you please supply the following details:

Account Name:                   _______________________ BSB: _________ ACCT. NO. _______________

* Please note that a 25% administration fee will be deducted from your test fee. Your refund will be deposited directly to your bank
  account or if preferred, a cheque will be mailed to your address in approximately
 3-5 weeks. We are unable to issue CASH refunds.

SIGNATURE:                      __________________________________




Office USE Only:                                                         DATE Sent to FSU:          ___/___/_____


IELTS REFUND STAMP HERE:




                                               UTS INTERNATIONAL               T +61 2 9514 1536                 Main Campus
                                               UTS IELTS Centre                F +61 2 9514 1824                 PO Box 123 Broadway
                                                                               E ielts@uts.edu.au                NSW 2007 Australia
                                                                                                                 T: +61 2 9514 1536
                                               Created on 16/06/2008 2:57:00                                     E: :ielts @uts.edu.au
                                               PM                                                                www.uts.edu.au/international/ielts

				
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Description: IELTS TEST CANCELLATION FORM