Request For Refund or Test Date Transfer Form Personal Details

Request for Refund or Test Date Transfer Form
Personal details
Title MRS
Given Names FATHIMA SHAMILA NAZEER
Surname SUKOORDEEN
Address
698/43 JIFFRY BAWA GARDEN, MABOLA
Telephone 0777265527
Email [email protected]
Test Date Registered for _ _ / _08

12 _ / _ 2021
_  Paper-based (PB)  Computer-Delivered (CD)
Passport Number N8829161
Exam Registration
A3-LK011-S-6240601 Eg: A3-LK001-S-1234567
Reference Number
Have you completed at
least one component of
 Yes  No
your test on this registered
test date?
Request is for (tick one
 Refund  Transfer
box only)
Centre name/number KANDY
Preferred New Test Date __/__/__  Paper-based (PB)  Computer-Delivered (CD)
(FOR TRANSFERS ONLY)
Candidate statement (to be completed by the candidate)

Please detail your grounds for applying for a refund or a test date transfer (attach extra sheet if there is
insufficient space).
Due to medical purpose as i am very ill and am unable to sit for the exam, i would like to refund
my examination fee as i dont think i will be physically well to sit for a higher qualification
examination. the supporting medical documents have been attached by scan.
Office Use Only

Customer Acknowledgement Slip
Refund Reference Number: ______________ Case Number: ______________
CSO Name and Signature: ______________ Date: ______________

Important Note
• All refund requests are subject to approval.
• Please do not discard or lose this reference slip as this will assist us in tracking your refund application
• Please ensure you quote the case number & refund reference number when you correspond to us via
email, when sending soft copies of passbook or statement of account. You may write to us on
[email protected]
(please turn over)

Payment Details (for Refunds only)
Bank Name: COMMERCIAL BANK Account Number 8010500954

Bank Details
Branch Name: WATTALA Payee Name: A.A,D NANDAWATHIE
Online
Payment 6492
Supporting Documents
Refunds Test Date Transfers
 Copy of bank passbook / statement details page,  Copy of passport

depicting Account Name and
 Supporting documents (if request made within five weeks and 5 days after the written test date)
Candidate Signature:
Type text here
Date: 19/08/2021
Test centre use only:

Refund Reference Number ____________________
CSO Name and Signature

Date Received
Registered test Date of prior Grounds for application

date application
Medical Personal Other
Request Approval  Approved  Not Approved

Authorised by IELTS Administrator:
Date:
Supporting documentation / evidence: Medical
(This form must be accompanied by an original medical certificate.)
Professional Practitioner Certificate (to be completed by medical practitioner)

Date/s of consultation:
Candidate affected on the test day (please circle appropriate letter):
A totally unable to sit exam specify period
B very severely affected but able to sit exam specify period
C severely affected but able to sit exam specify period
D moderately affected but able to sit exam specify period
E slightly affected but able to sit exam specify period
F unable to assess ability to sit exam specify period
Candidate affected at some time prior to the test day (please circle appropriate letter):
A totally unable to sit exam specify period
B very severely affected but able to sit exam specify period
C severely affected but able to sit exam specify period
D moderately affected but able to sit exam specify period
E slightly affected but able to sit exam specify period
F unable to assess ability to sit exam specify period
Remarks: nature of illness and other relevant information (with reference to the candidate’s capacity to sit an exam)
which will assist in any assessment of this application for special consideration.
Practitioner’s name:
Address:
Phone number:
Provider number: (if applicable): Stamp:
Signature: Date:
Supporting documentation / evidence: Other (police report, military service notice, death notice).
Please specify and attach relevant documentation/evidence
The information on this form is collected for the primary purpose of assessing your request for a refund/test date transfer. If you
choose not to complete all the questions on this form, it may not be possible for the test centre to process your request.

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Request For Refund or Test Date Transfer Form Personal Details

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Request for Refund or Test Date Transfer Form

Test Date Registered for _ _ / _08

Candidate statement (to be completed by the candidate)

Office Use Only

Refund Reference Number: Case Number:

CSO Name and Signature: Date:

(please turn over)

Bank Name: COMMERCIAL BANK Account Number 8010500954

Refunds Test Date Transfers

 Copy of bank passbook / statement details page,  Copy of passport

Test centre use only:

CSO Name and Signature

Registered test Date of prior Grounds for application

Request Approval  Approved  Not Approved

(This form must be accompanied by an original medical certificate.)

Professional Practitioner Certificate (to be completed by medical practitioner)

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