@TOEFL2013-14 TOEFL iBT REGISTRATION FORM

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

This form can be downloaded al www.ets.orgoetl. lf paying by electronic check (e-check), DO NOT complete this form. Register online at wvwr.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 country where you plan to test. See unrnrr.ets.orgftaefllibconactfor more information Completing this form and submitting payment will register you for the TOEFL iBT test. All information requested must be complete or your form will be returned. This form must be received 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.

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Print all informatian clearly. Be sure to enter yorir nanne exactly as t is shown on your prirnary identification document. Use black or blue ink.

testing in the United $tates,

U.S, Territorie$*, and Canada, mail the completed rsgistration form and payment tc: ETS-TOEFL iBT Registration Office PO Box 6151 Princeton, NJ 08541-6151 USA

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lf you are testing outside the United $tates, U.$, Territorleg*, and tanadr,
mail the ompleted form and payment tCI the RRS that services the country where you plan to test.

American $amoa, Guam, Puerto Rico,

and U.$. Virgin lslands

Test takers requesting testing accomrnodatisns: You must complete and submit this form to ETS Disability $ervices. To Set further information about reqrresting testing accommodaticns, use one of the comrnuniration rnethods listed on page 5 of 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 of

birth, and registration number

ltlame: Date of Blrth:

below.

Test Date:
Registration Number:

Copyright (c) 2013 by Educational Tesng Service. All rights

reserved.

Page 1 of 4

ETS, the ETS logos, TOEFL, and TOEL iBT are registered trademarks of Educational Testing Service {ETS) in the United States and other countires. ther products and services mentioned herein may b tradema*s of their respective ownes.

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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).
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Code for Gountry of Citizenship {refer to Bultefn}:

* ZIP or Postal Code:

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Hatve Gountry Code {refer to Buttetin};

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Date of Birth:

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ldentilioatisn Document io be pre$ented on test day:

Numbsr on ldentification Document: q "7_ c4, 5 .? t,,{ 3

Listed on ldentification Document:

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Phone Number include area rode, coun

code, or

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TSEFL iBT6 Registration Form fconfinued}

Name:

TEST LOCATION Choose 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 section of the TOEFL website, at www.ets.orgltoefl.

First Chsic* City Sode:

Gity Name:

country

Name:

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Seusnd Chrlice Sity Sade:

tity

Name:

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Sounlry Nams:

TEST DATE Specify five test dates in order of preference. For testing dates, see the Test Takers section of the TOEFL website at nnrrw.efs.orgltoefl. Please note that testing start times vary. This form must be received at ETS at least four weeks before your earliest test date choice. MM: Manth of the Year DD: Day of the

Msnth

YY: Year
DD MM DD

MM *Frsrchoice:
MM

DD

MM

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Eprhrrdchoice'lzftl
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lf your requested test date(s) cannot be accommodated, you will be scheduled for the next available test date unless you check the box below. So not re$hedule me, pl*ass return rny payrnnt,

OFFICIAL SCORE REPORT RECIPIENTS Using the Test Center and lnstitution Code list on the TOEFL website al www.ets.orgltaefl, indicate where you would like your officialscor 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 for graduate study, you must fill in 00 as the department code for each institution or agency you list.

1. $csre *eport Hecipint: Z. $ccre Report Recipientl

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lnstitution

Department

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3. $csre Heport frecipient:

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lnstitution

lnstitution

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4. $core Repsrt He*ipient:

lnstitution

Page S af 4

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TEST FEES

TSFFL i8T*Registration Fsrm {confinr,rcdJ

Narne:

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

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For all checks drawn on a U.S. bank, be aware thal you are authorizing ETS at its discretion to use the information o yCIul check to make a one-time electronic debit from your account for the amount of your check; no additional amount will be added, 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 future ETS test or service.

Please write, DO NOT FRINT, thefollowing statement and sign your name.
I hereby agre to the conditions set forth in the 2013-14 lnfonnation and Regisfration Bulletin, specifically those 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.

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Thank you for registering to take the TOEFL iBT test, Conffrmation of this registration will be sent to your email address. Do NOT send your registration form more than once. This will help avoid extra processing by TOEFL Serviees and unneces$ary charges to you. Page 4 of 4