Application for re-issuing Test Report Form (due to loss or damage)

1. Full Name: . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .

(These names must be the same as the names on your national identity document/passport)
2. Dr Mr Miss Ms (circle as appropriate)
3. Address for correspondence: . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .
. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .
5. Tel No.: .. . . . . . . . . . . . . . . . . Mobile No.: .. . . . . . . . . . . . . . . . . . . . . .

6. Email: .. . . . . . . . . . . . . . . . . .. . . . . .
7. Date of birth: . . . . /. . . . ./. . . .(day/month/year) Sex: F / M (circle as appropriate)

8. ID Type: Passport / National ID Card (circle as appropriate)

ID Document Number: .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .

9. Most recent test details:

Centre number: .. . . . . . . . . . . . . Centre Name: .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . .

Candidate number: .. . . . . . . . . . . . . . . . . .. . . . . . . . . . .
Date: . . . . . . / . . . . . . ./. . . . . . . (day/month/year)

10. Reason for re-issuing my Test Report Form (circle as appropriate)

Loss Damage

11. Option to receive my Test Report Form (tick only one option as appropriate)

o Self pick-up at the British Council office (an original ID document is required)

o Authorise another person to pick up the result on my behalf (a valid Authorisation letter is required, a template
could be found at https://www.britishcouncil.vn/thi/ky-thi-ielts)

I certify that the information on this form is complete and accurate to the best of my knowledge

Signature: . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . /. . . . . ./ . . . .

For Office use only:

Receipt number:

Received by: ………………date………..

(name & signature)

Proceeded by: ………………date…………..

(name & signature)