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:
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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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