NOT FOR SALE IELTS Application form Please return to: PLEASE WRITE IN BLOCK CAPITALS © Proterred date oftost Q Test city location © Last name (family name/sumame) © Tite (OanniNesintssnt) mist 1111 eRe © First (given) name(s) whe [i [-le[u|']| at] “These names mus be be same as he nares on your passporYNational Geriy Card ent rs appar inh sro over Which \ELTS test module are you taking? cick one boxonty) Academic iv] General Training Oo Please roe hats the carats resporsbity to seectho test module that best meets eirne0ds. “The General Tranny mode isnot avalabic on every test date Hgo0 SRP OER ROR UMA - PABA BA © Actress: Please note you vil ony be sent one copy of yourresuts. yA saRl-F-EHEA A «Ness NLR ITO @ reeprone Mobile number Q Ema Pease povte hil and accurate contact inbrmaton inca posta adress. phone and mobile nue an ena when ae in corstant and vad use ‘Th eet errs oth et partner may cana candies before orator he tat 0 ances the ul oe regition and admiration @ ow rom (UST TSTaTe © coon CF) enter BO A ae @Prease inate which document you wil be using es prot of Kenly and gve fe number below. cence ty el cee on coy ratte ae pat {orrun hng eB une ncaed bbe Tha tay om ty al vb edn ee dy For office use only psf AUR ‘scheme test date hr date of payment m receipt number ID chosked Administrator’ initials- ac sr Please tun over 1For questions 13-16 please enter codes and the name of the country of nationality and fist language. ‘You can find codes on pages iiiv, Please take care and enter this information accurately. Itthe codes you enter here are incorrect, the information on your Test Report Form will also be incorrect. eountry of nationaty (code) 1-9 2) BIMSB OM. BSSMALAR Liv MBNA ‘Country of nationality (name) [TAIWAN @prstianguage (code) 0 2/1 First language (name) | CHINESE © occupation cece [Ts Wren please specty [| ‘Occupation (level) [0 [1 Mother, pleasespecty |, @ wny are youtaking ne test? [0 JB] —trother, please specity G Which country are you applying tointending to go 10? (wc one vox ony) Australia Canada | _|NewZealand |_| Republic of ireland United Kingdom | United States of America other, please spacity here are you currently studying English (i applicable)? British Council, RSM LB ELIS RRR A ; BRR N/A @ What evel of education have you completed? (ex ne tox ony ‘secondary upto 16 years | secondary 1619 years | V/| degree or equivalent postgraduate mie ae am AB SU @ How many years have you been studying English? (ta one box ony) roortesstnan) | | 2) 13) 45 | |6|_|7{ | 8[¥ s(ormorey @ bo you nave a permanent cabity, such a8 a visual, heang or specie leaming eiffel, whieh require special arrangements (for example, modified material, extra time, use of technology, etc.)? [rie [vim It yes, please specify your requirements below. You must attach original supporting medical evidence to this form. ‘The medical evidence must be in the form of a report prepared in a period no more than two years before the test date. You must submit requests for modified test materials atleast three months before the test. SELBASOENER TASH BR AAG BSRBTAG WSAA A SAM LEP BREAFZASO-Notice to Candidates Candidates engaging in malpractice wl nt be alowed to complete he est ant ‘wl steele an IELTS tet esl. Cancdates who ae found to have ‘You must {engages m mabpracce on test cay afer er result has Deen ssved Wl Nave . ‘et ecu canes. Candidates engaging n magractce maybe reprted 0 + prove pro ot your ienty (passport or Natonl went Cars) at action Fealsaton. Cort ne es correo cant whic ype or ent Goeumerts accapled. Candles taking the ast cust net own county fmustuse a passport, inkrm te cenze of any changes to your identy document before the test = Gate Ifyou oo not do hs you wilt be alowed o take the est and you wil fatbe aigbie or a eund ans ting we same senty document on be test day a8 the ane recorded in your appli Iyou do ol dos you wi be alowed ake the fest an youl robe eight fora retuned or taser ‘are atthe cate before the schecses let slat tine. I you ave ae, ou wil not be allowed to lake Ie fest and you wi ot be ete fr leave al personal belongings nthe designated belongings area. The ony ems you may bang it he test focm af your aproved tent document, Sandra pen(), enc) and erasers), and abo of wate betes} A ‘econic cevces anda watches must be etn the belongings are ana ‘must be sued of. You may be leconealy Scanned for aewees at any fame cum ne est day. Ay canaate who breaches ese conan wl ot eceve an IELTS test rut or be eigble fora retundor ans. While {he centre lake a reazonacle measures to secure your tems nine atongings area, ey cannot be held responsible or ay ss. ‘onsen or your ent tobe vies btn at test registaton and on test ay. Tis may nea having you photograph taken. You wil be required otemporanty remove “ny covering em your face. Any caeate who retuses nave a [photograph taken wl nol be alowes to sith es and wil a be ented {o.aretund The photograph taken bythe cen wll appear on your Test Report For. = proving a sample of your satu having your finger sean taken, koep ray te olowng tems on your desk your aenty doc encas) erasers, aa abate of water (abel es) 1 t,o Test cone will charge an asst fe op b 25% of you canel your fest win fir wocks ofthe est dat or any reason apart ‘tom medical Ones, you willbe eget recelvearefure you cael ‘your te or request a anstr wihin ve weeks othe test dat mesieal Teasons, you must provide supporting medial evidence wii ve working ‘ays oF he test date. Gry evince oF seriousness wl be consioee. ‘Only orignal mecca cereates wl be acepted and must stata to appear forte test on he scheduled test cate ‘The IELTS Tes Partners recognise and support ne nto IELTS test canaiates to prvacy _ymen you powde your ent ntraton the IELTS Test Parner ink ‘rat iirmaton fo our IELTS tet and test rest one Test Report Fm. This enavies you to subml your Test Rapert Ferm io Recognisng “Organisations and for em over your rest ‘Test Report Foms wi ony beset o thse Recogising Orgaesatons romatod bythe canddatem her appeaton or atthe request he Canvoate ater ove of resus. When a cana subs a Test Report Fm os Recognng Grgansaien they consent the venican 0 he reultby that orgaresaton. “The IELTS Test Parnes ce aus representatives may share Candas personal ala ng wie onan et prtrmanee Sere ‘ala or petograps ken by De cente wih edueanal tutes, ‘governments (ncn visa provessng anomie), pessoal bodies and merc ergansatons tat recognse IELTS sees (Recognsng ‘Orgnisatons) ow erflxcenentagerces and egualay abodes ‘whee required fr veraton purposes oe purpeses pee the TELTS test and fs starenoaes aganst ary fom of alprace. Finger scan {ala where oan wi a be seed oan ey except he fELTS ~aaruptng| ‘eat Parner fereuang any pa othe extn any mes ‘The ELTS Test Partners wil otin work roued by Cancale in he epan IELTS test and may Use tx Qual eon! purposes ano rwestgsOns| ino suspected maracice Tent score daa and est responses, a “anonymous oan may abo Be Used tr maton, Teseareh aes! ‘rang purposes.Codes to enter for questions 13-16 Refer to the lists below for the codes to enter for your country of nationality, your first language and ‘your occupation. If either your first language or your country of nationality is not listed, enter ‘000’. Look for the closest description of your occupation and proposed area of study. If your work or position is not covered at all, then enter ‘00° Question 13 - Country of nationality ‘gansta oo ‘Aan sands 2 Algeria NESEURRRESS ESESRREESESE98 Sines Sines esa ciara Now cad at few zen Hs ae an Newom dona ans Noe Hy Se (aan cy tte) Ni Fos tie Hong kona ie Nixon tne Hany stom ana ats eae Nery sa Saar ores Pan oi Repco Pas foe Pasine tena Panama to Pag new cana ‘a ro “an Pris Sn Prem ican Poona rena ong roa Pinto area, Democrat Peps or Reblog fre, pune tose rowan Stetoarnseny ‘ota Democrat Sarvhauna, canon ara eoune ‘aan bs ci, SESRE98 88888 B38 oo 2 oo we 20 0 os 2a os 20 or 08 oa oo om 00 036, 033 os 08 20, on os, #8 Bae Lsbanon ‘santLuca ber ‘Sant Pree ad Miqueton ‘Samoa SRRRECSRREERELETaasian Tarcani, Unted Repuote ot Trane Timorese Togo Tokelau Tongs, ‘Tina and Tooago Tunsia Turkey Turkmenistan Turks and Caos sands Tala Uganda Ukraine Unites rab Emirates ned Kingdom United States of America utying anes Question 14 — First Language SIIGSSERRRLARSGTTGHTARHRIRESESEELRESESRSESREERSESLERRER BEGLRRERRSERRELERRRLEITIRATQuestion 15 - Occupation Example If you are a student, enter 08 because the sector is Education and 7 because the level is Student. Checklist eggsaeese | have signed the Application Form. have provided all the information required. I have paid the test fee. (Please note that your application will not be processed -without this.) Ihave attached a photocopy of my passport / National Identity Card (pages showing personal identification details and expiry date). 2 4 ° 6 7 ° Question 16 — Why you are taking the test For higher eduction extend cause 1 (tee menins or mere) Foc tight eduction short couse {tee ments eriss) For oer eouraton purposes Forrogatraton asa ctor Forimmigiaion Forempioyment For professional regstation (NOT medica For personal reasons For fegsvaion asa nurse ¢ruaing CGFNS) For regtraton 35a entst omer CAMBRIDGE ENGLISH Language Assessment CeO eae ECCApplications to Recognising Organisations @ Please give details below of academic institutions/government agencies/professional bodies/employers you would lke your result sent to. Add your fllease number if known. Results may be sent ether electronically or by post to these: organisations, Please complete al details below for the centre to correctly entity Recognising Organisations. The contre may charge a postal fee for results sent internationally- or by courier. The Test Report Form will not be sent to rmigration or education agents, Please note that organisations you have listed below may access your results before you have received or viewed them. a) Name of personidepartment Wet /Ulr¥+ R09 | Name of insttution/agency/bodylempioyer #t2/°5)/#818 818 Filelease number 3:48 Offer Letter - SIAC HAMM Address xxexae) | | | | xmns =} b) Name of personidepartment | = Name of institution/agency/bodylemplayer Filetoase number Address ©) Name of person/dey d) Name of intitutior SUMALOASA-HEAMMAFSE - SLA MMMBUS AAA SL Ee NAL SaRPER RN AL « SRNL RSPEI - REITER « BARES NA REAAUBBERA - WRB « ALA A RA RS SN A. CER RSE STNE ALIA BRAK (ADA TORI AR NT100) an co Ene NT 30 (893 B) SRE ma NT 150 (#8 1-2 8) NT 300 (#8 3-5 8) UPS / DHL. NT 700 (#8 3B)Declaration 1 acknowedge that the IELTS tests jointy owned by Britsh Counel IELTS Australia Py Lid (ABN 84 008 664 765), whichis whol owned by IDP cation Ld (IDPIELTS Austra’ and Cambridge Engish Language Assessinent (part ofthe University of Cambridge, collectively refered to as the IELTS Test Partners. 2. {cory thatthe information in my application is completo, tue and accurate, ‘3. understana mat ne personal data n my apples is colected for he Purposes the IELTS tes, and consent ors data to be dscoseato, processes and sved by he IELTS Test Parte’ othe purpose f such amnisralon. Rarer consent forts al, incudng wihout tae, test perfomance or ‘sae dala and my es resto be dclosed by he IELTS Test Parnes to hase Recognising Organisations fo which | apply and to goverment (nciding sa processing authori) othe purpose of alowng these orgarisations o vent my est esu oro cary ou nurs ination to suspected malpractice. Ie IELTS Test Parner discover tat false orale Test Repor Frm has been provided to any of hese Recognising Organisations or government ‘autores fuer consent ha the IELTS Test Parnes may form he same and provide them vi ry personal data and any relevant dots rlaing othe work | produce a par of my ost taking, ncn, wihut lation, test perfomance or score dat. 4. undorstand that my personal data may be processed in an anonymous frm by Ue IELTS Test Partners for statistical and research purposes. Tho IELTS Test Parnes and the cere adminsterng the test contin that they vl ot disclose personal information about candidates to others except ‘a sated nthe Declaration of othe extent peti by fw 5. understand that | may view a copy of my personal data contained in the Application Form by contacting ieksMcambridacendlish og. | understand that foe willbe charged fr access to tis information. 6. understand that f want a copy of my finger scan it can only be provided as a Binary Large Object (BLOB) and the request must be made to (els@ido.com or is @bntshcounci.og. | understand a fe wil be charged for access to ths information. 7. understand that the deta on this form are not completed my applicabon may not be processed. futher understand that completing and _submiting this Appcation Form does not guarantee registration on my prefered test date or at my prefered test lation. Vunderstand that my registration vl be canfrmed in uring from the centre 8. understand that any personal data collected during the identi verification process by the cere ether attest registration or on test day willbe processed and securely stored by the IELTS Test Partners forthe purpose of te IELTS test | acknowledge that the photograph taken of me by the ‘entre vl be provided to any Recognssing Organisations or goverment auhorties (ncluding visa processing authori) to which apply or the purposes of allowing these organisations to very my test resus of to cany out enquies in relation to possible malpractice or test integrity issues. 1 ‘understand that where inger scan datas bamed wil not be dclosed fo any enfily excep the IELTS Test Partners 9. understand that I wil have my photograph taken by the centre tallow the Test Report Form tobe released | have not had my photograph taken by the centre no resut willbe sued. 10. Lacknowiedge that have ead the IELTS Notice fo Gandidates on page ‘and agree to abide by the rules and regulations contained therein. 17. understand there may be local terms and condtions | must comply wih and that the cere wil provide details ofthese on request 12. | understand that | must aiend all four test components inorder o receive an IELTS test result and that any exception fo this must be approved in ‘advance by the centre 18. understand thatthe IELTS Test Partners have a responsibilty to all candidates and Recognising Organisations to ensure the highest confidence in the accuracy and interty of est resus and that he IELTS Test Partners therefore reserve the night to wthhold test results temporary or permanently ort cancel test rests which have been issued, # they consider those rests to be unreliable fr reasons of suspected malpractice or ‘any athe ereguanty inthe test proces. “4. understand that my resutt may not be issued 1S day flor he tes if any ofthe IELTS Tost Pariners doom it necessary to reviw any mater associated wh my {estore agmistaon of my test. nducng making enquries a o wheter any res o fequatons have Been treated. | understand Wat may be required 10 ‘Provide adatiora! samples of my wring nd speaking er he Purposes of assisting any ives iaton Before oar he test | understand that in exceptional cicumstances | may be required to re-take one or more IELTS components 15. understand that am suspected of engaging inary form of malpracie, or do anything that might damage the integriy and security of IELTS, | may not recene a test result my test fee wil not be refunded and | maybe prohibited rom taking the IELTS test nthe future. Despte and without imfing any ofthe terms of this Declaration, I understand that detais of any malpractice (neluding evidence of suspected malpractice) that has been estabiihed, suspected, or being formally investgated may be provided to Recognising Organisations, including visa processing authors and appropriate regulatory aurhories, or otherwise disclosed in accordance with the law, where requited for verticaton purposes or other purposes 1 protect the IELTS test and its stakeholders agains any form of malpractice. Yurher understand that suspected malpractice willbe reperted central to {he IELTS Test Partners and to any relevant est cen bythe entre where the suspecled malpractice occurred, 16. understand that if anyother person attempts to take the IELTS test in my piace, both | and such person wil be Kable to prosecution. Details reating to he stuation wil be provided othe relevant authors, including visa processing authories and appropriate requiatoy authortes. 117-1 understand that the work produce inthe IELTS fet remains the propery ofthe IELTS Test Partners. It will ot be released to candidates 0 0 instiutions or organisations, excep inthe investigation of suspected malpractice whereby my work may be provided to relevant authors. 418. understand that my Speaking test wil be recorded. | understand that nthe event he test des nat recor | vl be required torte the Speaking {est | also agree that an observer may attend my Speaking test as par ofthe monitoning process. 19. | undorstand that | wil be chargod the ful ost foe i cancel my test orrequost a transfor win five wooks ofthe test date, unless I provide ‘appropiate medical evidence, witin ve days ofthe test dale, o suppor te cancellation of ans. 20. acknowledge that Ihave rea the LTS Informaten for Caiftes bookie. Disclaimer: The International Engle Language Testing System (IELTS) is designed to be one of many factors used by academic insttuions, government ‘agencies, professional bodes and employers in determining whether a test taker can be admied as a student or be considered for employment or for Clizenship purposes. IELTS is no desiged fo be the sole method of determining admission ar employment forthe est faker IELTS is made available ‘worlwide o all persons, rgardlss of age, gonder, race, nationality er oon, buts not recommended to porcons under 16 yoars of age. ‘vst Couned, IOP: IELTS Austrata and Cambridge Engsh Language Assessment and any ole party Invoed in ceatng, producing, or detvenng IELTS shal not be lable for any direct, mdenta, consequent, indrec, special, punitive, or smiar damages arsing out of access to, use o, ‘acceptance by, or interpretation ofthe resus by any third party, or any eros or omissions in the content thereot BRITISH Bj CAMBRIDGE ENGLISH Ss e8UNeL | Zaidp * 4 ~ “© uctes 2018 | ceMsuanyor *8ZELB9PLSS..