Refund, Transfer and Credit Card Form Form to be completed and signed by candidate Allow 2 weeks for your refund to be processed ECC IELTS Test Centre ECU Mt Lawley Campus Building 10, 2 Bradford St MT LAWLEY WA 6050 E:
[email protected] P: 6279 1164
Family name
Given name
Passport number
Date of birth
/
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Address Email
Mobile
Refunds – complete savings/credit card details below - money can only be refunded to the same account Cancel test $247.50 - test fee, less $82.50 administration fee Test date booked___ / ___ / ___ Academic/General Receipt number: EoR $176.00 - refund after a successful Enquiry on Results
Why you are applying for a refund or transfer?________________________________________________________ ____________________________________________________________________________________________ Signature of candidate: ________________________________________________ Date _____________________ Your refund or transfer is at the Test Centre Administrator’s discretion. Please provide evidence to support your application and attach your receipt.
Credit card payment
Cost
GST only payment for test on _ _ /_ _ /_ _ _ _
$33
Transfer to another test date Preferred new test date: _ _ /_ _ /_ _ _ _
Location: Joondalup/Mt Lawley
$82.50
Module: Academic/General
Enquiry on Results (EoR)
$176
Preparation Course for IELTS 2017
$270 TOTAL AMOUNT TO CHARGE MY CREDIT CARD
CREDIT CARD – complete details Charge my credit card (amount shown above) Card number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Card expiry: __ __ / __ __
CCV number: __ __ __
Card type: Visa/Mastercard
(circle one)
The credit card verification (CCV) number is the last 3 digits found on the back of the card.
Name of cardholder: _______________________________ Phone number:
______________________________
Cardholder signature: _____________________________________________
Date: ______ / ______ / ______
Address of cardholder: _________________________________________ Suburb: __________________________ Postcode: _____________________________________
Mobile number: _______________________
EFTPOS (savings account) – complete details Bank name: ____________________________________ Account Name: BSB: __ __ __ __ __ __
Last updated 11/08/2017
________________________________
Account Number: ____________________________________________________
ABN 35 064 377 993
Office Use Only (IELTS) Refunds
Approved by Administrator. Signature: __________________________ EOR Refund Evidence attached Original receipt retrieved, photocopied Application moved to refund folder Sent copy to Finance
Amount paid Less fees Refund due
$ __________________ - $ __________________ = $ __________________
Transfers Approved by Administrator. Signature: __________________________ New test date: ______ / ______ / ______ Module: Academic / General Receipt for administration fee of $82.50 attached or administration fee waived at discretion of Administrator If candidate number already generated in IWAS, enter RF into record Transfer candidate record to new IWAS test date Application moved to new test date folder Candidate number from original test date: __ __ __ __ __ __
Office Use Only (ECC – Credit card refunds) Terminal transaction no: ___________________ Maze Receipt Number: ______________________ Processed by: __________________________________
Date processed: ______ / ______ / ______
Office Use Only (FSS – EFTPOS refund) Transaction Description
Account Code
Period
Amount
Inv/Jnl/Pay
Transaction no:____________ Issue date:____________ Bank GL code:____________ Processed:____________ SIGNED/AUTHORISED: __________________________________ (Accountant)
Last updated 11/08/2017
Date: ______ / ______ / ______