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Authorization Form for Applications (1)
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IELTS UBC Vancouver Test Centre Official IELTS Test Centre
Fax: 604-822-1477 Email: [email protected]
Web: www.ielts.ubc.ca
Credit Card Payment Authorization Form
IELTS Test Application
Test Fee
Price Quantity Total
IELTS Test Fee $295 $ Includes tax Total $
For payment by Visa or Mastercard, please complete the following information, then fax the form to +1-604-822-1477. NOTE: PLEASE DO NOT EMAIL THIS FORM. If sent via email, it will not be processed. Card Holders Name: _____________________________ ___________________________________
(First name) (Last name)
Credit Card: Master Card Visa
Credit Card Number: ___________________________________________________________________
Expiry Date: _________________ CVD (3 digits on back of credit card): _______________
I authorize the University of British Columbia to charge $___________________ CAD to my credit card.
Signature of Card Holder: __________________________________ Date: ________________________
Test date: _________________ Academic General Training (DD/MM/YYYY)
Candidate Name: ________________________________ _____________________________________ (First name) (Last name)
Address: ______________ __________________________ (Unit #) (Street) _________________________ ________________________ (City) (Zip/Postal Code)
Email: ____________________________
For Office Use Only:
Receipt No: __________________ Date: ______________ SRS #: ______________ Processed by: _____________