ELS Language Services – IELTS Testing [http://www.els.

edu/en/DiscoverELS/IELTS]

Location where you applied to take the IELTS Exam: Cincinnati, OH

CREDIT CARD AUTHORIZATION FORM

Candidate’s Name: __________________________________ / ____________________

(Family Name) (First Name)
Test Date: ______________ Test Module (Circle One): Academic General

Telephone: _____________________ 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): _____________________________________________

Cardholder’s Relationship to Candidate: _____________________________________

Card Number: ____________________________ Security Code: __________

Expiration Date: ______ / ______ Amount to be charged: US$ ___________

MM YY

Description of Charge: IELTS Exam

Billing Address: ______________________________________________

______________________________________________

______________________________________________

Cardholder’s Signature: _________________________________ Date: ___________