IELTS Preparation Courses Application Form

Personal Details: Family name: _______________________________________________________ First Name(s): _______________________________________________________ Title: _______________________________________________________ Address: _______________________________________________________ _______________________________________________________ Telephone Number: _______________________________________________________ E-mail: _______________________________________________________ Nationality: _______________________________________________________ Date of Birth: ___/___/______ Sex: Male / Female Do you have any disabilities? Yes / No If yes, please specify: ____________________________________________________________

Which IELTS test do you need to take? Academic ☐ General ☐

Have you ever taken IELTS before? Yes ☐ No ☐ If yes, when and what score? _______________________________________________________ If no, how would you describe your level? Beginner ☐ / Intermediate ☐ / Advanced ☐

IELTS One Day Workshop

Saturday from 10.00am – 4.00pm with a one hour lunch break. Please tick to select a date.

Date Fee Please tick ✓ Optional Exam Dates *

18 October 2014 £69 25/10/14 (A only) 8/11/14 (A only) 22/11/14 (A&G) 6/12/14 (A&G)

13/12/14 (A&G) 17/1/15 (A only)

7/2/15 (A&G) 28/2/15 (A&G) 14/3/15 (A&G)

21/3/15( A only) 28/3/15 (A&G) 18/4/15 (A&G)

25/4/15 (A only) 9/5/15 (A&G)

16/5/15 (A only) 30/5/15 (A&G) 6/6/15 (A only) 13/6/15 (A&G) 11/7/15 (A&G)

25/7/15 (A only) 1/8/15 (A&G)

29/8/15 (A&G)

29 November 2014 £69

24 January 2015 £69

21 February 2015 £69

21 March 2015 £69

16 May 2015 £69

20 June 2015 £69

18 July 2015 £69

22 August 2015 £69

10 Saturdays from 10.00am – 1.00pm with a 15 minute break

Wednesday evenings from 5.45 pm to 8.45 pm. Please tick to select a date.

A place on an IELTS Course does not guarantee you a place on your preferred IELTS test date. As there are limited spaces on these tests, I would encourage you to send in your application (separate form) as soon as possible, as spaces are allocated on a first come, first served basis. You can apply online at https://ielts.britishcouncil.org/universityofsurrey

The course fee does not include the exam fee.

I understand that my fees for the course are not transferable or refundable if my application is accepted. Signature: ______________________________ Date: __________________________

IELTS Weekend Preparation Course

Start Date Finish Date Fee Please tick ✓

27 September 2014 29 November 2014 £420

24 January 2015 28 March 2015 £420

18 April 2015 20 June 2015 £420

IELTS Evening Preparation Course

Start Date Finish Date Course

Fee*

Please

Tick✓ Optional Exam Dates *

24/9/14 15/10/14 £169 25/10/14 (A only)

5/11/14 26/11/14 £169

8/11/14 (A only) 22/11/14 (A&G) 6/12/14 (A&G)

13/12/14 (A&G) 17/1/15 (A only)

7/2/15 (A&G)

28/1/15 18/2/15 £169 28/2/15 (A&G) 14/3/15 (A&G)

21/3/15( A only)

4/3/15 25/3/15 £169 28/3/15 (A&G) 18/4/15 (A&G)

25/4/15 (A only)

15/4/15 6/5/15 £169 9/5/15 (A&G)

16/5/15 (A only) 30/5/15 (A&G)

27/5/15 17/6/15 £169 6/6/15 (A only) 13/6/15 (A&G) 11/7/15 (A&G)

1/7/15 22/7/15 £169 25/7/15 (A only)

1/8/15 (A&G) 29/8/15 (A&G)

Please return your application form and payment to: IELTS Administrator University of Surrey Library and Learning Centre School of English and Languages (15LC03) Guildford, Surrey GU2 7XH Email: ielts@surrey.ac.uk Tel: +44 (0)1483 689912 or 6222 http://www.surrey.ac.uk/englishandlanguages/study/ielts/preperation_courses/

Receipt: RC:

IELTS PAYMENT BY DEBIT/CREDIT CARD

"I understand that my test fees are only refundable or transferable up to 5 weeks before my test date (minus an administration fee of £30). Less than 5 weeks before my test I am liable to lose my full test fee unless I can provide adequate medical proof to support my application to cancel or postpone." "I understand that my course fees are not transferable or refundable if my application is accepted. I note that IELTS courses are not eligible for a student visa."

Signature: Date:

NAME OF APPLICANT/ CANDIDATE:

CARD NUMBER:

EXPIRY DATE:

START DATE if on card:

CARD TYPE, e.g. Visa, Visa debit, MasterCard (NB: NO Amex taken)

AMOUNT PAYING: Please tick

IELTS Official Practice Materials 2 (with DVD): £15 ☐

IELTS Evening Preparation Course: £169 ☐

IELTS Exam 2014 : £140 ☐

IELTS Exam 2015 : £150 ☐

IELTS One Day Workshop: £69 ☐

IELTS Weekend Preparation Course: £420 ☐

SECURITY NUMBER: FINAL 3 DIGITS ON BACK OF CARD

ISSUE NUMBER: SWITCH & SOLO If no issue number, start date

CARDHOLDER NAME IF DIFFERENT TO APPLICANT:

CARDHOLDER ADDRESS IF DIFFERENT TO APPLICANT:

CARDHOLDER TEL:

DATE DETAILS TAKEN: (For office use)

TAKEN BY (NAME): (For office use)