@TOEFL-2013-14 TOEFL iBT REGISTRATION FORM

Rqrsüer online at www.ets.orgytrefl. lt's last and easy!

This form can be downloaded al www.ets.orgÁoetl.

lf paying by electronic check (e-check), DO NOT complete this form. Register online atwvwr.ets.argfioetl, call l-443-751-4862 or 1-800-GO-TOEFL (within the United $tates, U.S.Territories*, or Canada), or callthe Regional Registration Center (RRC) that services the countrywhere you plan to test. See unrnrr.ets.orgftaefllibíconüactfor more information

Completing this form and submitting payment will register you for the TOEFL iBT test. Allinformation requested must be complete or your form will be returned. This form must bereceived at ETS at least four weeks before your earliest test date choice.

Note: Be sure to complete alllour pages and, if necessary, staple the completed form before mailing.

r Print all informatian clearly. Be sure to enteryorir nanne exactly as ¡t is shown on yourprirnary identification document.

' Use black or blue ink.

I lf you are testing outside the United$tates, U.$, Territorleg*, and tanadr,mail the üompleted form and payment tCI

the RRS that services the country whereyou plan to test.

* American $amoa, Guam, Puerto Rico,and U.$. Virgin lslands

lü testing in the United $tates,U.S, Territorie$*, and Canada, mailthe completed rsgistration form andpayment tc:

'''ETS-TOEFL iBT Registration OfficePO Box 6151Princeton, NJ 08541-6151 USA

Test takers requestingtesting accomrnodatisns: You mustcomplete and submit this form to ETSDisability $ervices. To Set further informationabout reqrresting testingaccommodaticns, use one of thecomrnuniration rnethods listed on page 5of this Sufletin or gCI to vtrww,ets,arg/disabilff.

lf you have previously taken an ETS iBT-delivered test, please indicate your name, test date, date ofbirth, and registration number below. 6

ltlame: Test Date:

Date of Blrth: Registration Number:

Copyright (c) 2013 by Educational Tesüng Service. All rights reserved. Page 1 of 4ETS, the ETS logos, TOEFL, and TOEñL iBT are registered trademarks of Educational Testing Service {ETS) in the

United States and other countires. óther products and services mentioned herein may b€ tradema*s of their respective owneÍs.

ls13-'14 TOEFL iBT* Hegistration Fsrm (confinued}

All required fields must be completed, or your form will be returned. Required fields are noted with an asterisk {i).* Last fFamilvl$urnamel Name las on Bhots lD):

Middle Narne or Middle lnitial hoto lD):

* nUdre$s Line 1:

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Address Line 2:

Address Line 3:

Addrese Line 4:

* st"t* or Frovince:

W* Code for Gountry of Citizenship {refer to Bultef¡n}:

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ldentilioatisn Document io be pre$ented on test day:

Numbsr on ldentification Document:

* ZIP or Postal Code:

€ C t q O { ü 4* Hat¡ve Gountry Code {refer to Buttetin};

tr,ltlul* Native Languáge Gsde {refer to Sulletrn}:

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* Country Code for this Mailing Address {refer to Eutferrn}:

* Date of Birth:

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Listed on ldentification Document:

* Ptim" Phone Number include area rode, coun code, or

$econda Phone Nurnber inelude area code

Page 2 al 4

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t{H3-f 4 TSEFL iBT6 Registration Form fconfinued} Name:

TEST LOCATIONChoose two test locations in order of preference. Print the city name and country name for each choice.For locations and city codes, see the Test Center and lnstitution Gode list in the Test Takers sectionof the TOEFL website, at www.ets.orgltoefl.

* First Chsic* City Sode:

Gity Name:

country Name: tCUO({O?' ,, _

* Seusnd Chrlice Sity Sade:

Qu:eVü,furhtity Name:

Sounlry Nams:

TEST DATESpecify five test dates in order of preference. For testing dates, see the Test Takers section ofthe TOEFL website at nnrrw.efs.orgltoefl. Please note that testing start times vary. This formmust be received at ETS at least four weeks before your earliest test date choice.

MM: Manth of the Year

MM DD

DD: Day of the Msnth YY: Year

MM DD MM DD

MM DD

lnstitutionffilnstitutionm

DepartmenttilDepartmentil:

3. $csre Heport frecipient:

4. $core Repsrt He*ipient:

ffilnstitution

*F¡rsrchoice: En ffi Eprhrrdchoice'lzftl m EpFi*hchoice: m EE [HMM $D

secondchqice: m Eq [HFoutthchoica:m m ffilf your requested test date(s) cannot be accommodated, you will be scheduled for the next availabletest date unless you check the box below.

So not re$ühedule me, pl*ass return rny payrn€nt,

OFFICIAL SCORE REPORT RECIPIENTSUsing the Test Center and lnstitution Code list on the TOEFL website al www.ets.orgltaefl, indicatewhere you would like your officialscoré reports sent. The Department Code list is also in the Bulletin.Enter a department code only if you are applying for graduate study. lf you are not applying forgraduate study, you must fill in 00 as the department code for each institution or agency you list.

" lnstitution1. $csre *eport Hecipi€nt:

Z. $ccre Report Recipientl

Page S af 4

ts13-{4 TSFFL i8T*Registration Fsrm {confinr,rcdJ Narne:

TEST FEES

The TOEFL iBT test fee varies by country. To find out what the fee is for your testing location, go to the TOEFL website,select "Register for the Test," and choose your tesl location. lnlormation about payment policies is in the Bulletin.Fees are subjec-t to change without notice.

TOEFL iBTteslfee............. ..$ Utr

Add Value-Added or similar taxes where applicable... ......................$

TOTAL AMOUNT DUE (DO NOT SEND CASh)........

PAYIIIENT {lnformation about payment policies ie in the Bulletin.l

Payment type: (check one) ffi CreditlDebit Card* fJ Cfrect< f euro Check f, Money Order

lf paying by crediUdebit card, indicate which card you aré using, and enter your card number, expiration date, and thecardholder's name in the spaces below.Your card will be billed for all services you request on this form. Any debiVcheck cardbranded with one of the five accepted credit oard logos can be used.SEND ITTO ETS.TOEFL, PO BOX 6151, PRINCETON NJ 08541.6151, USA.

tl Ameriean Expre$$@ tl Discsver@ JCBs tl MasterCard@ VISA€

Expiration Date

ffimHNanre ün CreditlDebit Card

Month Year

For all checks drawn on a U.S. bank, be aware thal you are authorizing ETS at its discretion to use the information oñ yCIul

check to make a one-time electronic debit from your account for the amount of your check; no additional amount will beadded, lf you do not have Sufficient funds in your account, an additional service fee of US$20 will be added to your account.All outstanding balances incurred from prior ET$ tests or services must be paid in full in order to register for any futureETS test or service.

Please write, DO NOT FRINT, thefollowing statement and sign your name.

I hereby agrée to the conditions set forth in the 2013-14 lnfonnation and Regisfration Bulletin, specificallythose concerning test administration, payment of fees, the reporting of scorea, and the confidentiality of test questions.I cerlify that I am lhe person who will take the test and whose name and address appsar on this form.

#redit/Debit üard Nurnber

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signatur*' EPiCI¿q Li !'\düo f . r.,".

Thank you for registering to take the TOEFL iBT test, Conffrmation of this registration will be sent to youremail address. Do NOT send your registration form more than once. This will help avoid extra processing byTOEFL Serviees and unneces$ary charges to you.

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