Personal details Title:
Name: Surname: Patronymic:
Address:
Telephone: Email:
Test date registered for: / /
R equest is for (tick one box): Refund Test Date Transfer
Centre name/number (UZ025 by default):
Preferred new test date: / /
Please select the test that you registered for: ☐ IELTS (Paper Based) ☐ Computer-delivered IELTS ☐ IELTS for UKVI (Paper Based)
☐ IELTS for UKVI (Computer-delivered) ☐ Life Skills A1 ☐ Life Skills A2 ☐ Life Skills B1
Please select the test that you wish to transfer to: ☐ IELTS (Paper Based) ☐ Computer-delivered IELTS ☐ IELTS for UKVI (Paper Based)
☐ IELTS for UKVI (Computer-delivered) ☐ Life Skills A1 ☐ Life Skills A2 ☐ Life Skills B1
Candidate statement (to be completed by the candidate) Please state your reasons for applying for a refund or a test date transfer.
In case of medical reasons, this form must be accompanied by an original medical certificate issued by a Professional Medical Practitioner. The medical certificate must include nature of illness and other relevant information (with reference to the candidate’s capacity to sit an exam) which will assist in any assessment of this application for special consideration.
For other reasons, please attach relevant documentation/evidence (police report, military service notice, death notice).
(attach extra sheet if there is insufficient space).
