TOEFL® PAPER-BASED TEST REFUND REQUEST FORM

TOEFL® PAPER-BASED TEST REFUND REQUEST FORM
Follow the completion instructions on the reverse side of this form and mail it to:
TOEFL®
PO Box 6151
Princeton, NJ 08541-6151 USA
Name:
Family Name (Surname)
Given Name
Middle Initial
Address (include ZIP or postal code):
Daytime Telephone Number:
Date of Birth:
Appointment Confirmation/
Registration Number:
Canceled Test Date:
Month
Day
Year
Month
Day
Year
Candidate Number (if applicable):
Copyright © 2014 by Educational Testing Service, Princeton, NJ
CUT HERE
TOEFL® PAPER-BASED TEST SCORE REVIEW REQUEST FORM
Check the appropriate box and complete the form. Instructions for submitting the form are on the reverse side.
I request that the following be rescored:
□ TOEFL® PBT answer sheet (US$25)
□ TWE® essay (US$50)
Test Date:______________________________________ Registration Number:_________________________________
Month
Day
Test Center Number:
Year
Name:
Date of Birth:
Month/Day/Year
Address (include ZIP or postal code): __________________________________________________________________
_________________________________________________________________________________________________
□ Check this box if your mailing address has changed since the test date indicated above. Print your new address below.
Address (include ZIP or postal code): __________________________________________________________________
_________________________________________________________________________________________________
Check if paying by
□ American Express®
□ Discover®
□ JCB®
Credit/Debit Card Number
1222222222222222
□ MasterCard®
□ VISA®
Expiration Date
12–12
Month
Year
Copyright © 2014 by Educational Testing Service, Princeton, NJ
2011-12 TOEFL PBT Bulletin
Forms \ 19
COMPLETING THE REFUND REQUEST FORM
�
A partial refund is available if the proper procedures are followed when canceling a test. Information
about canceling a test, program refund policies, refund processing times, and requirements for
completing this form are in the Information and Registration Bulletin for TOEFL Paper-based Testing.
Complete the form and send it to the address shown. Refunds will be issued in U.S. dollars.
Be sure to include:
•
•
•
•
•
•
•
Your complete name
Your address (including ZIP or postal code)
Daytime phone number
Date of birth
Appointment Confirmation/Registration number
Canceled test date
Candidate number (if applicable)
If applicable, return your unused admission ticket with the form.
CUT HERE
SUBMITTING A SCORE REVIEW REQUEST FORM
Complete the form and send it with the required fee to:
TOEFL Services
ETS
PO Box 6151
Princeton, NJ 08541-6151 USA
Only one request can be submitted for a specific test administration. Checks must be payable to
ETS-TOEFL. In Canada, add GST/HST (Reg. No. 131414468 RT) and QST (Reg. No. 1087967545) to
total remittance. Add Value-Added or similar taxes where applicable. By sending your check to us, you
authorize ETS to convert the check into an electronic funds transfer. Please be aware that your bank
account may be debited the same day we receive your payment and you will not receive a canceled
check. If you are paying by credit/debit card, this form may be faxed. Faxed requests will not be
processed unless complete credit/debit card information is provided. The fax number is 1-610-290-8972.
The results of the score review will be available approximately three weeks after receipt of your
request form and payment.
NOTE: All forms will be processed upon receipt, and a charge will be made to your credit/debit card. If
you think your faxed form may not have been received by TOEFL Services, and you attempt to send the
information again, write “DUPLICATE” in large letters on all repeat requests. This will help avoid extra
processing by TOEFL Services and unnecessary charges to your credit/debit card.
Print
20 \ Forms
2011-12 TOEFL PBT Bulletin