CREDIT CARD COMPANY NAME

AUTHORIZATION FORM 225 Language Street, New York, NY 21000

T: 250-2222-1456
E: companyname.here@gmail.com

CANDIDATE DETAILS

JOHN DOE
Name

5/15/2021 Level 9 - Expert

Test Date Module

john.doe@dreamgmail.com
Email

(555) 02560 0000

Phone #

I authorize COMPANY NAME to charge my credit card in the amount indicated below to process my IELTS
test registration. I agree to the IELTS cancellation and refund policies as per the IELTS Notice to Candidates
and Terms and Conditions included in the online test registration.

I authorize COMPANY NAME International to charge below credit card for the following:

Test Fee ($220.00) $285.00

Payment in USD ($)
Transfer Fee ($65.00)
International Courier ($70.00)
Delivery Within US ($15.00)
Cardholder's Signature
Additional TRF ($50.00)
Other 1 (Lorem Ipsum) 5/15/2021
Date
Other 2 (Lorem Ipsum)

CREDIT CARD DETAILS

JOHN DOE
Name (As it appears on the credit card)

VISA MasterCard American Express Other (write)

Credit Card Type

3959 03-2026
Security Code (3/4 Digits) Expiration Date
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