ELS Language Centers IELTS Testing [http://www.els.

edu/en/DiscoverELS/IELTS]
Select aSelect Location LOCATION where you applied to take the Exam: Click to Location

CREDIT CARD AUTHORIZATION FORM

CANDIDATES NAME: (FAMILY NAME) TEST DATE: TELEPHONE:

/ (FIRST NAME)

Clickto toSelect Select Module Test Module: Click Module

E-MAIL ADDRESS:

I authorize ELS Language Centers to charge my credit card as indicated below and I agree to be bound by the IELTS cancellation, postponement, and refund policies as outlined on the IELTS Application Form. NAME (as it appears on card): CARDHOLDERS RELATIONSHIP TO CANDIDATE: CARD NUMBER: SECURITY CODE

EXPIRATION DATE: MM

/ YY

AMOUNT TO BE CHARGED: US$

DESCRIPTION OF CHARGE:

BILLING ADDRESS:

CARD HOLDERS SIGNATURE: TYPE OF CARD: Click to Credit Select Credit Select Card Card

TODAYS DATE: 19-Jun-13 17-Sep-09

Please fill this form out electronically, print and sign it.