Credit Card Authorization Form

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ELS Language Centers – IELTS Testing  [ http://www.els.edu/contents/ielts_testing.aspx?idtab=132 ] 
 
Circle the LOCATION where you want to take the Exam: 
 
Atlanta, GA 

Boston/Newton, MA 

Cambridge, MA  

Charlotte, NC  

Chicago/River Forest, IL  

Cleveland, OH  

Grand Rapids, MI 

Honolulu, HI 

Houston, TX  

Indianapolis, IN 

Las Vegas, NV 

Melbourne, FL

Nashville, TN 

New York, NY 

Oklahoma City, OK 

Orlando, FL  

Pttsburgh, PA

Portland, OR 

Ruston, LA 

St. Petersburg, FL 

St. Paul, MN 

San Antonio, TX 

San Francisco, CA 

Santa Monica, CA 

Teaneck, NJ

St. Louis, MO
Santa Barbara, CA 

 

 

CREDIT CARD AUTHORIZATION FORM 
 
CANDIDATE’S NAME: _______________________________/________________________________ 
(FAMILY NAME) 

 (FIRST NAME) 

 
TEST DATE: ____________________________ 
 
TELEPHONE: ___________________________ E‐MAIL ADDRESS ___________________________________ 
 
 
I authorize ELS Language Centers to charge my credit card as indicated below and I agree to be bound by the 
IELTS cancellation, postponement, and refund policies as outlined on the IELTS Application Form. 
 
TODAY’S DATE: _____________________________________ 
 
NAME (as it appears on card): ____________________________________________________ 
(FIRST NAME)  

(FAMILY NAME) 

 
CARDHOLDER’S RELATIONSHIP TO CANDIDATE: __________________________________ 
 
CARD NUMBER: _____________________________________ SECURITY CODE ____________ 
EXPIRATION DATE: ________/_________ 
 
 
(month)               (year) 
 

AMOUNT TO BE CHARGED: US$ ________________ 
 
DESCRIPTION OF CHARGE AND BILLING ADDRESS: _________________________________ 
 
______________________________________________________________________________________ 
 
CARD HOLDER’S SIGNATURE: _____________________________________ 
 
PLEASE ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE CREDIT CARD TO THIS SHEET. 
 
TYPE OF CARD: 
_____ VISA 
 
 _____ AMERICAN EXPRESS 
_____ MASTERCARD 
 _____ DINER’S CLUB 
_____ JCB 

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