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: _____________
