Thomson Prometric Voucher Purchase Form Email firstname.lastname@example.org or Fax +60 (0)3-7628-2266 PURCHASER INFORMATION Date: For Office Use Only Company Name: Received Date: Order placed by/ Contact Person: Contact Phone No: Contact Fax No: Due Date: Contact Email Address: APTC Site Code (when applicable): Membership Number (CTEC, CompTIA etc): Discount Type: Address Line 1: Address Line 2: City: Registration No.: Postal Code: State: Country: Payment clearance No. VOUCHER ORDER INFORMATION 1 2 3 4 Client/Exam Name (MS, CISCO etc): Exam Code: Sent date: Quantity: Price per exam: Total Amount: Expiry Date: Site Specific (Y/N): Exam Specific (exam code needed): Reset by U.S. (tick if yes) PLEASE INDICATE YOUR PAYMENT METHOD: SELECT ONE OF THE OPTIONS BELOW: (Your order can only be processed once payment has been received and cleared) Manual Entry (tick if yes) CREDIT CARD Credt Card Type (Please check): AMEX MASTER VISA Marketing Exp charge to: Name of Cardholder: Card Number: Expiration Date: Remarks: CHEQUE Please make cheques payable to Prometric Thomson Learning Post to Voucher Department, PO Box 5343, Chatswood NSW 2067, Australia. VAR: DIRECT DEPOSIT/ MONEY TRANSFER Please advise country you wish to deposit from and we will email you appropriate account number for your deposit. Terms & Conditions: (Please read carefully before placing the order) 1. Voucher orders cannot be canceled. 2. Voucher expiration dates cannot be extended. 3. The minimum quantity per order are 3 vouchers. 4. All vouchers are country-specific; please clarify country of redemption upon ordering. Vouchers are not transferable to other regions/countries. 5. Purchaser is responsible for supplying the relevant membership numbers, or market price will be applied. 6. Please clearly indicate the exam code, if applicable. 7. Please visit www.register.prometric.com for most current exam price. 8. Payments must clear in Prometric account before vouchers will be issued. For EFT, kindly fax the bank remittance to +60 3 7628 2266 for tracking purposes. 7. All promotional vouchers are on pre-paid basis only. 9. For payments made via credit card, please fax the credit card approval letter, credit card authorisation form and photo copy of the credit card to 6 03 7628 2266 (front & back) at +60 3 7628 2266.