NOT FOR SALE Application form Please return to: PLEASE WRITE IN BLOCK CAPITALS 1 Preferred date of test d d m m y y second choice d d m m y y 2 Test city location 3 Last name (family name/surname) 4 Title (Dr/Mr/Mrs/Miss/Ms) 5 First (given) name(s) 16 These names must be the same as the names on your passport/National Identity Card and must appear in the same order. 6 Which IELTS test module are you taking? (tick one box only) Academic General Training Please note that it is the candidate’s responsibility to select the test module that best meets their needs. The General Training module is not available on every test date. 7 Address: Please note you will only be sent one copy of your results. Zip/Postal code 8 Telephone Mobile number 9 Email Please provide full and accurate contact information including postal address, phone and mobile number and email which are in constant and valid use. The test centre or the test partner may contact candidates before or after the test to access the full test registration and administration. 10 Date of birth d d m m y y 11 Gender F M (circle as appropriate) 12 Please indicate which document you will be using as proof of identity and give the number below. Candidates taking the test outside their own country must use a current passport. You must bring the ID document indicated below to the test. This is the only form of identity that will be accepted on the test day. The document must be valid/not expired at registration and on the test day. Passport National Identity Card Passport or National Identity Card number For office use only scheme test date d d m m y y date of payment receipt number d d m m y y ID checked Administrator’s initials AC GT Please turn over 1 For questions 13–16 please enter codes and the name of the country of nationality and first language. You can find codes on pages ii–iv. Please take care and enter this information accurately. If the codes you enter here are incorrect, the information on your Test Report Form will also be incorrect. 13 Country of nationality (code) 11 12 Country of nationality (name) 14 First language (code) First language (name) 15 Occupation (sector) 13 if other, please specify Occupation (level) if other, please specify 16 Why are you taking the test? if other, please specify 17 Which country are you applying to/intending to go to? 15 (tick one box only) Australia Canada New Zealand Republic of Ireland United Kingdom United States of America other, please specify 18 Where are you currently studying English (if applicable)? 19 What level of education have you completed? 21 (tick one box only) secondary up to 16 years secondary 16–19 years degree or equivalent 20 How many years have you been studying English? 22 postgraduate (tick one box only) 1 (or less than) 2 3 4 5 6 7 8 9 (or more) 23 21 Do you have a permanent disability, such as a visual, hearing or specific learning difficulty, which requires special arrangements (for example, modified material, extra time, use of technology, etc.)? yes no If yes, please specify your requirements below. You must attach original supporting medical evidence to this form. The medical evidence must be in the form of a report prepared in a period no more than two years before the test date. You must submit requests for modified test materials at least three months before the test. 2 Notice to Candidates IELTS test terms and conditions You must … • provide proof of your identity (passport or National Identity Card) at registration. Contact the test centre to confirm which type of identity document is accepted. Candidates taking the test outside their own country must use a passport. • inform the centre of any changes to your identity document before the test date. If you do not do this you will not be allowed to take the test and you will not be eligible for a refund or transfer. • bring the same identity document on the test day as the one recorded in your application. If you do not do this you will not be allowed to take the test and you will not be eligible for a refund or transfer. • arrive at the centre before the scheduled test start time. If you arrive late, you will not be allowed to take the test and you will not be eligible for a refund or transfer. • leave all personal belongings in the designated belongings area. The only items you may bring into the test room are your approved identity document, standard pen(s), pencil(s) and eraser(s), and a bottle of water (label-free). All electronic devices and all watches must be left in the belongings area and must be switched off. You may be electronically scanned for devices at any time during the test day. Any candidate who breaches these conditions will not receive an IELTS test result or be eligible for a refund or transfer. While the centre will take all reasonable measures to secure your items in the belongings area, they cannot be held responsible for any loss. • consent for your identity to be verified both at test registration and on test day. This may include: – having your photograph taken. You will be required to temporarily remove any covering from your face. Any candidate who refuses to have a photograph taken will not be allowed to sit the test and will not be entitled to a refund. The photograph taken by the centre will appear on your Test Report Form. – providing a sample of your signature. – having your finger scan taken. • keep only the following items on your desk: your identity document, pen(s), pencil(s), eraser(s), and a bottle of water (label-free). Candidates engaging in malpractice will not be allowed to complete the test and will not receive an IELTS test result. Candidates who are found to have engaged in malpractice on test day after their result has been issued will have their result cancelled. Candidates engaging in malpractice may be reported to regulatory authorities globally and may be liable to legal action. Your IELTS test result • Results are issued by centres, usually 13 days after the test. • You will receive only one copy of your Test Report Form. Replacement copies are not issued in the event of loss or damage. • The Test Report Form will be issued in your name as it appears on the identity document used at registration. If you find that your personal details are incorrect on the Test Report Form, please contact the centre where you took the test. Documentation must be provided to verify the correct details. If you change your name after receiving your Test Report Form, the name will not be changed on the Test Report Form. • Your result may not be issued 13 days after the test if the IELTS Test Partners decide that it is necessary to review any matter associated with your test or the administration of your test. To assist any investigation, you may be required to provide writing and speaking samples. In exceptional circumstances you may be required to re-take one or more IELTS components. • Your result may be cancelled after it has been issued if any irregularity is identified. You may be required to re-take one or more IELTS components. • Your result will be disclosed to the Recognising Organisations which you nominated in your application or to which you applied with your Test Report Form, for the purpose of allowing those organisations to verify the result or to carry out any enquiries in relation to suspected malpractice. • If any of the data on the Test Report Form provided by you or your agent to Recognising Organisations has been altered in any way, your original test result may be cancelled. • Candidates are not permitted access to the work they produce in the IELTS test. • tell the invigilator at once if you think you have not been given the correct question paper or if the question paper is incomplete or illegible. Cancelling your IELTS test o r requesting a transfer • raise your hand if you need to ask the invigilator something. Candidates may not ask for, and will not be given, any explanation of the test questions. • If you cancel your test or request a transfer five weeks or more before the test date, the test centre will charge an administration fee of up to 25% of the test fee. • attend all four components of the test. If you do not attend all four components, you will not receive an IELTS test result. Exceptions are possible but must be requested at registration and written approval must be received from the centre. • inform the invigilator on the day of the test if you believe that your performance may be affected by ill health, by the way in which the test is delivered at the centre or for any other reason. If you have a complaint relating to the delivery of the test, you must submit your complaint to the test centre before you leave the centre on test day. Complaints relating to the delivery of the test will not be accepted after test day. • leave all test materials in the test room at the end of the test. The test materials include question papers, Speaking booklets, answer sheets and rough paper. Any candidate who attempts to remove test materials from the test room will not receive an IELTS test result. You must not … • talk to or disturb other candidates once the test has started. • lend anything to, or borrow anything from, another candidate during the test. • eat or smoke in the test room. • leave the test room without the permission of the invigilator. • leave your seat until all test materials have been collected and you have been told you can leave. • engage in any form of malpractice which may damage the integrity and security of the IELTS test. Malpractice includes, but is not limited to: – attempting to cheat in any way, including using notes of any kind from any source. – helping another candidate to cheat. – impersonating another candidate or having another candidate impersonate you. – copying the work of another candidate. – disrupting the test in any way. – reproducing any part of the test in any medium. – attempting to alter the data on the Test Report Form. • If you cancel your test within five weeks of the test date for any reason apart from medical ones, you will not be eligible to receive a refund. If you cancel your test or request a transfer within five weeks of the test date for medical reasons, you must provide supporting medical evidence within five working days of the test date. Only evidence of serious illness will be considered. Only original medical certificates will be accepted and must state inability to appear for the test on the scheduled test date. How IELTS uses your information • The IELTS Test Partners recognise and support the right of IELTS test candidates to privacy. • When you provide your identity information the IELTS Test Partners link that information to your IELTS test and test result on the Test Report Form. This enables you to submit your Test Report Form to Recognising Organisations and for them to verify your result. • Test Report Forms will only be sent to those Recognising Organisations nominated by the candidate in their application or at the request of the candidate after the issue of results. When a candidate submits a Test Report Form to a Recognising Organisation they consent to the verification of the result by that organisation. • The IELTS Test Partners or their authorised representatives may share candidate personal data including without limitation test performance or score data or photographs taken by the centre with educational institutions, governments (including visa processing authorities), professional bodies and commercial organisations that recognise IELTS scores (‘Recognising Organisations’) or law enforcement agencies and regulatory authorities where required for verification purposes or other purposes to protect the IELTS test and its stakeholders against any form of malpractice. Finger-scan data, where obtained, will not be disclosed to any entity except the IELTS Test Partners. • The IELTS Test Partners will retain work produced by candidates in the IELTS test and may use it for quality control purposes and for investigations into suspected malpractice. Test score data and test responses, in an anonymous form, may also be used for informational, research, statistical or training purposes. *Important: Please detach this section (pages i–iv) and retain for your own records. i Codes to enter for questions 13–16 Refer to the lists below for the codes to enter for your country of nationality, your first language and your occupation. If either your first language or your country of nationality is not listed, enter ‘000’. Look for the closest description of your occupation and proposed area of study. If your work or position is not covered at all, then enter ‘00’. Question 13 – Country of nationality Afghanistan001 Åland Islands 237 Albania002 Algeria003 American Samoa 004 Andorra005 Angola006 Anguilla238 Antarctica239 Antigua and Barbuda 007 Argentina008 Armenia009 Aruba223 Australia010 Austria011 Azerbaijan012 Bahamas013 Bahrain014 Bangladesh015 Barbados016 Belarus017 Belgium018 Belize019 Benin020 Bermuda021 Bhutan022 Bolivia, Plurinational State of 023 Bonaire, Sint Eustatius and Saba 240 Bosnia and Herzegovina 024 Botswana025 Bouvet Island 241 Brazil026 British Indian Ocean Territory 242 Brunei Darussalam 027 Bulgaria028 Burkina Faso 029 Burundi031 Cambodia032 Cameroon033 Canada034 Cape Verde 036 Cayman Islands 038 Central African Republic 039 Chad040 Chile041 China (People’s Republic of) 042 Christmas Island 243 Cocos (Keeling) Islands 244 Colombia043 Comoros044 Congo045 Congo, Democratic Republic of the 219 Cook Islands 046 Costa Rica 047 Côte d’Ivoire 096 Croatia048 Cuba049 Curaçao245 Cyprus050 Czech Republic 051 Denmark052 Djibouti053 Dominica054 Dominican Republic 055 Ecuador056 Egypt057 ii El Salvador 058 Equatorial Guinea 059 Eritrea060 Estonia061 Ethiopia062 Falkland Islands 224 Faroe Islands 063 Fiji064 Finland065 France066 French Guiana 067 French Polynesia 068 French Southern Territories 246 Gabon069 Gambia070 Georgia071 Germany072 Ghana073 Gibraltar074 Greece075 Greenland076 Grenada077 Guadeloupe078 Guam079 Guatemala080 Guinea081 Guinea-Bissau082 Guyana083 Haiti084 Heard Island and McDonald Islands 247 Holy See (Vatican City State) 212 Honduras085 Hong Kong 086 Hungary087 Iceland088 India089 Indonesia090 Iran, Islamic Republic of 091 Iraq092 Ireland093 Israel094 Italy095 Jamaica097 Japan098 Jordan099 Kazakhstan100 Kenya101 Kiribati102 Korea, Democratic People’s Republic of 103 Korea, Republic of 104 Kosovo235 Kuwait105 Kyrgyzstan226 Lao People’s Democratic Republic106 Latvia107 Lebanon108 Lesotho109 Liberia110 Libya111 Liechtenstein112 Lithuania113 Luxembourg114 Macao115 Macedonia, the Former Yugoslav Republic of 225 Madagascar116 Malawi117 Malaysia118 Maldives119 Mali120 Malta121 Marshall Islands 122 Martinique123 Mauritania124 Mauritius125 Mayotte227 Mexico126 Micronesia, Federal States of 228 Moldova, Republic of 128 Monaco129 Mongolia130 Montenegro131 Montserrat132 Morocco133 Mozambique134 Myanmar135 Namibia136 Nauru137 Nepal138 Netherlands139 New Caledonia 141 New Zealand 142 Nicaragua143 Niger144 Nigeria145 Niue146 Norfolk Island 229 Northern Mariana Islands 230 Norway147 Oman148 Pakistan149 Palau231 Palestine150 Panama151 Papua New Guinea 152 Paraguay153 Peru154 Philippines155 Pitcairn156 Poland157 Portugal 158 Puerto Rico 159 Qatar160 Réunion161 Romania162 Russian Federation 163 Rwanda164 Saint Barthélemy 248 Saint Helena, Ascension and Tristan Da Cunha 180 Saint Kitts and Nevis 181 Saint Lucia 182 Saint Martin (French Part) 249 Saint Pierre and Miquelon 183 Saint Vincent and the Grenadines 184 Samoa217 San Marino 165 Sao Tome and Principe 166 Saudi Arabia 167 Senegal168 Question 14 – First Language Serbia169 Seychelles170 Sierra Leone 171 Singapore172 Sint Maarten (Dutch Part) 250 Slovakia173 Slovenia174 Solomon Islands 175 Somalia176 South Africa 177 South Georgia and the South Sandwich Islands 251 South Sudan 252 Spain178 Sri Lanka 179 Sudan185 Suriname186 Svalbard and Jan Mayen 232 Swaziland187 Sweden188 Switzerland189 Syrian Arab Republic 190 Taiwan192 Tajikistan233 Tanzania, United Republic of 193 Thailand194 Timor-Leste222 Togo195 Tokelau196 Tonga197 Trinidad and Tobago 198 Tunisia199 Turkey200 Turkmenistan234 Turks and Caicos Islands 201 Tuvalu202 Uganda203 Ukraine204 United Arab Emirates 205 United Kingdom 206 United States of America 209 United States Minor Outlying Islands 253 Uruguay207 Uzbekistan210 Vanuatu211 Venezuela213 Vietnam214 Virgin Islands, British 236 Virgin Islands, U.S. 208 Western Sahara 216 Yemen218 Zambia220 Zimbabwe221 Other000 Afrikaans001 Akan002 Albanian003 Amharic004 Arabic005 Armenian006 Assamese007 Aymara008 Azeri 009 Baluchi010 Bambara011 Basque012 Bemba013 Bengali014 Bihari015 Bosnian901 Breton016 Bulgarian017 Burmese018 Byelorussian019 Catalan020 Chinese021 Creole022 Croatian023 Czech024 Danish025 Dari026 Dutch028 Dzongkha027 Efik029 English030 Estonian031 Ewe032 Faeroese033 Farsi034 Fijian035 Filipino904 Finnish036 Flemish037 French038 Fulani039 Ga040 Galician903 Georgian041 German042 Gilbertese043 Greek044 Gujarati045 Haitian Creole 046 Hausa047 Hebrew048 Hindi049 Hungarian050 Ibo/lgbo051 Icelandic052 Igala053 Indonesian054 Irish137 Italian055 Japanese056 Javanese057 Kannada058 Kashmiri059 Kazakh060 Khmer061 Korean062 Kurdish063 Lao064 Latvian065 Lithuanian066 Luba067 Luo068 Luxemburgish069 Macedonian902 Malagasy070 Malay071 Malayalam072 Malinka073 Maltese074 Maori075 Marathi076 Marshallese077 Masai078 Mende079 Mongolian080 Nepali081 Norwegian082 Oriya083 Palauan084 Pashto086 Polish087 Ponapean088 Portuguese089 Punjabi085 Pushtu090 Quechua091 Rajasthani092 Riff093 Romanian094 Romansch095 Russian096 Samoan097 Scottish Gaelic 138 Serbian098 Setswana099 Shona100 Sindhi101 Singhalese102 Slovak103 Slovene104 Somali105 Spanish106 Swahili107 Swazi108 Swedish109 Tagalog110 Tahitian111 Tamil112 Tatar113 Telugu114 Tetum136 Thai115 Tibetan116 Tigrinya117 Tongan118 Trukese119 Tulu120 Tupi/Guarani121 Turkish122 Uighur123 Ukrainian124 Ulithian125 Urdu126 Uzbek127 Vietnamese128 Welsh139 Wolof129 Xhosa130 Yao131 Yapese132 Yiddish133 Yoruba134 Zulu135 Other000 Please turn over iii Question 15 – Occupation Example If you are a student, enter 08 because the sector is Education and 7 because the level is Student. 0 8 7 Sector Administrative Services 01 Agriculture, Fishing, Forestry, Mining 02 Arts and Entertainment 03 Banking and Finance 04 Catering and Leisure 05 Construction Industries 06 Craft and Design 07 Education08 Health and Social Services 09 Installation, Maintenance and Repair Services 10 Law and Legal Services 11 Manufacturing and Assembly Industries 12 Personal Services 13 Retail Trade 14 Technical and Scientific 15 Telecommunications and the Media 16 Transport17 Utilities (gas, water etc.) 18 Wholesale Trade 19 Other00 Level Self-employed1 Employer/Partner2 Employee (Senior level) 3 Employee (Middle or Junior level) 4 Worker in the home 5 Retired6 Student7 Other0 Checklist I have signed the Application Form. I have provided all the information required. I have paid the test fee. (Please note that your application will not be processed without this.) I have attached a photocopy of my passport / National Identity Card (pages showing personal identification details and expiry date). Question 16 – Why you are taking the test For higher education extended course 1 (three months or more) For higher education short course 2 (three months or less) For other education purposes 3 For registration as a doctor 4 For immigration 5 For employment 6 For professional registration (NOT medical) 7 For personal reasons 8 For registration as a nurse (including CGFNS) 9 For registration as a dentist 10 Other0 iv * Important: Please detach this section (pages i–iv) and retain for your own records. Applications to Recognising Organisations 22 Please give details below of academic institutions/government agencies/professional bodies/employers you would 24 like your result sent to. Add your file/case number if known. Results may be sent either electronically or by post to these organisations. Please complete all details below for the centre to correctly identify Recognising Organisations. The centre may charge a postal fee for results sent internationally or by courier. The Test Report Form will not be sent to migration or education agents. Please note that organisations you have listed below may access your results before you have received or viewed them. a) Name of person/department Name of institution/agency/body/employer File/case number Address b) Name of person/department Name of institution/agency/body/employer File/case number Address c) Name of person/department Name of institution/agency/body/employer File/case number Address d) Name of person/department Name of institution/agency/body/employer File/case number Address e) Name of person/department Name of institution/agency/body/employer File/case number Address Please turn over 3 Declaration 1. I acknowledge that the IELTS test is jointly owned by British Council, IELTS Australia Pty Ltd (ABN 84 008 664 766), which is wholly owned by IDP Education Ltd (‘IDP:IELTS Australia’) and Cambridge English Language Assessment (part of the University of Cambridge), collectively referred to as the IELTS Test Partners. 2. I certify that the information in my application is complete, true and accurate. 3. I understand that the personal data in my application is collected for the purposes of the IELTS test, and I consent for this data to be disclosed to, processed and stored by the IELTS Test Partners for the purpose of such administration. I further consent for this data, including, without limitation, test performance or score data and my test result to be disclosed by the IELTS Test Partners to those Recognising Organisations to which I apply and to governments (including visa processing authorities) for the purpose of allowing these organisations to verify my test result or to carry out enquiries in relation to suspected malpractice. If the IELTS Test Partners discover that a false or altered Test Report Form has been provided to any of these Recognising Organisations or government authorities I further consent that the IELTS Test Partners may inform the same and provide them with my personal data and any relevant details relating to the work I produce as part of my test taking, including, without limitation, test performance or score data. 4. I understand that my personal data may be processed in an anonymous form by the IELTS Test Partners for statistical and research purposes. The IELTS Test Partners and the centre administering the test confirm that they will not disclose personal information about candidates to others except as stated in this Declaration or to the extent permitted by law. 5. I understand that I may view a copy of my personal data contained in the Application Form by contacting [email protected] I understand that a fee will be charged for access to this information. 6. I understand that if I want a copy of my finger scan it can only be provided as a Binary Large Object (BLOB) and the request must be made to [email protected] or [email protected] I understand a fee will be charged for access to this information. 7. I understand that if the details on this form are not completed my application may not be processed. I further understand that completing and submitting this Application Form does not guarantee registration on my preferred test date or at my preferred test location. I understand that my registration will be confirmed in writing from the centre. 8. I understand that any personal data collected during the identity verification process by the centre either at test registration or on test day will be processed and securely stored by the IELTS Test Partners for the purpose of the IELTS test. I acknowledge that the photograph taken of me by the centre will be provided to any Recognising Organisations or government authorities (including visa processing authorities) to which I apply for the purposes of allowing these organisations to verify my test results or to carry out enquiries in relation to possible malpractice or test integrity issues. I understand that where finger-scan data is obtained it will not be disclosed to any entity except the IELTS Test Partners. 9. I understand that I will have my photograph taken by the centre to allow the Test Report Form to be released. If I have not had my photograph taken by the centre no result will be issued. 10.I acknowledge that I have read the IELTS Notice to Candidates on page i and agree to abide by the rules and regulations contained therein. 11.I understand there may be local terms and conditions I must comply with and that the centre will provide details of these on request. 12.I understand that I must attend all four test components in order to receive an IELTS test result and that any exception to this must be approved in advance by the centre. 13.I understand that the IELTS Test Partners have a responsibility to all candidates and Recognising Organisations to ensure the highest confidence in the accuracy and integrity of test results and that the IELTS Test Partners therefore reserve the right to withhold test results temporarily or permanently, or to cancel test results which have been issued, if they consider those results to be unreliable for reasons of suspected malpractice or any other irregularity in the test process. 14. I understand that my result may not be issued 13 days after the test if any of the IELTS Test Partners deem it necessary to review any matter associated with my test or the administration of my test, including making enquiries as to whether any rules or regulations have been breached. I understand that I may be required to provide additional samples of my writing and speaking for the purposes of assisting any investigation before or after the test. I understand that in exceptional circumstances I may be required to re-take one or more IELTS components. 15.I understand that if I am suspected of engaging in any form of malpractice, or do anything that might damage the integrity and security of IELTS, I may not receive a test result, my test fee will not be refunded and I may be prohibited from taking the IELTS test in the future. Despite and without limiting any of the terms of this Declaration, I understand that details of any malpractice (including evidence of suspected malpractice) that has been established, is suspected, or is being formally investigated may be provided to Recognising Organisations, including visa processing authorities and appropriate regulatory authorities, or otherwise disclosed in accordance with the law, where required for verification purposes or other purposes to protect the IELTS test and its stakeholders against any form of malpractice. I further understand that suspected malpractice will be reported centrally to the IELTS Test Partners and to any relevant test centre by the centre where the suspected malpractice occurred. 16.I understand that if any other person attempts to take the IELTS test in my place, both I and such person will be liable to prosecution. Details relating to the situation will be provided to the relevant authorities, including visa processing authorities and appropriate regulatory authorities. 17.I understand that the work I produce in the IELTS test remains the property of the IELTS Test Partners. It will not be released to candidates or to institutions or organisations, except in the investigation of suspected malpractice whereby my work may be provided to relevant authorities. 18.I understand that my Speaking test will be recorded. I understand that in the event the test does not record I will be required to re-take the Speaking test. I also agree that an observer may attend my Speaking test as part of the monitoring process. 19.I understand that I will be charged the full test fee if I cancel my test or request a transfer within five weeks of the test date, unless I provide appropriate medical evidence, within five days of the test date, to support the cancellation or transfer. 20.I acknowledge that I have read the IELTS Information for Candidates booklet. Disclaimer: The International English Language Testing System (IELTS) is designed to be one of many factors used by academic institutions, government agencies, professional bodies and employers in determining whether a test taker can be admitted as a student or be considered for employment or for citizenship purposes. IELTS is not designed to be the sole method of determining admission or employment for the test taker. IELTS is made available worldwide to all persons, regardless of age, gender, race, nationality or religion, but it is not recommended to persons under 16 years of age. Signature 4 Date d d m m y y © UCLES 2016 | CE/4949/6Y01 *6514681328* British Council, IDP: IELTS Australia and Cambridge English Language Assessment and any other party involved in creating, producing, or delivering IELTS shall not be liable for any direct, incidental, consequential, indirect, special, punitive, or similar damages arising out of access to, use of, acceptance by, or interpretation of the results by any third party, or any errors or omissions in the content thereof.
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