Refund or transfer form


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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



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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: _ _ /_ _ /_ _ _ _

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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: ______ / ______ / ______