<p> IELTS Preparation Course Application Form</p><p>Personal Details Family name: ______First Name(s): ______Title: ______Address: ______Please attach a ______recent passport sized photo ______Telephone Number: ______Fax Number: ______E-mail: ______Nationality: ______Date of Birth: ___/___/______Sex: Male / Female</p><p>∙Which IELTS test do you need to take? Academic ☐ General ☐</p><p>∙What date are you planning to take your test? ___/___/_____ (see next page)</p><p>∙Where are you planning to take the test? ______</p><p>∙Have you ever taken IELTS before? Yes / No If so: When? ______Score? ______</p><p>Medical Conditions ∙Do you have any disabilities? Yes / No ∙Specify: ______</p><p>Receipt # RC# Which IELTS preparation course would you like to take?</p><p>Course Please Exam Dates Start Date Finish Date Fee* Tick ✓ (optional) IELTS a 22/2/12 14/3/12 £159.00 Fully 17/3/12 (A only) booked 21/4/12 (A&G) IELTS b 18/4/12 9/5/12 £159.00 12/5/12 (A&G) 19/5/12 (A only)</p><p>IELTS c 23/5/12 13/6/12 £159.00 16/6/12 (A only) 30/6/12 (A&G) IELTS a 27/6/12 18/7/12 £159.00 21/7/12 (A&G)</p><p>* Classes are held on Wednesday evenings from 5.45 pm to 8.45 pm *Please Note: ●A place on a Preparation Course does not guarantee you a place on your preferred IELTS test date. As there are limited spaces on these tests, I would encourage you to send in your application (separate form) as soon as possible, as spaces are allocated on a first come, first served basis. ●The course fee does not include the exam fee.</p><p>I understand that my fees for the course are not transferable, or refundable, if my application is accepted. I note that this part-time evening course is not eligible for a student visa. Signature: ______Date: ______</p><p>Contact the English Language Support Team at [email protected] or Tel: +44 (0) 1483 689912 http://www2.surrey.ac.uk/languages/study/englishprogrammes/ielts/ielts_preparation_courses.ht m</p><p>Please return application form and payment to: IELTS Administrator University of Surrey Library and Learning Centre School of English and Languages (15LC03) Guildford, Surrey GU2 7XH UK</p><p>- 2 –</p><p>IELTS PAYMENT BY DEBIT/CREDIT CARD NAME OF APPLICANT:</p><p>CARD NUMBER:</p><p>EXPIRY DATE: START DATE if on card: CARD TYPE, e.g. Visa, Visa debit, MasterCard (NB: NO Amex taken) AMOUNT PAYING: Please tick Exam: £125 Course: £159</p><p>SECURITY NUMBER: FINAL 3 DIGITS ON BACK OF CARD ISSUE NUMBER: SWITCH & SOLO If no issue number, start date</p><p>CARDHOLDER NAME IF DIFFERENT TO APPLICANT: CARDHOLDER ADDRESS IF DIFFERENT TO APPLICANT: CARDHOLDER TEL:</p><p>DATE DETAILS TAKEN: (For office use) TAKEN BY (NAME): (For office use) "I understand that my test fees are only refundable or transferable up to 5 weeks before my test date (minus an administration fee of £20). Less than 5 weeks before my test I am liable to lose my full test fee unless I can provide adequate medical proof to support my application to cancel or postpone."</p><p>"I understand that my course fees are not transferable, or refundable, if my application is accepted. I note that this part-time evening course is not eligible for a student visa."</p><p>Signature: Date: </p>