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4/%&, )NTERNET BASED 4EST I"4 2%')342!4)/. &/2-


34/0 2EGISTER ONLINE AT WWWETSORGTOEFL )TS FAST AND EASY

4HIS FORM CAN BE DOWNLOADED AT WWWETSORGTOEFL

)F PAYING BY CREDIT CARD $/ ./4 COMPLETE THIS FORM 2EGISTER ONLINE AT WWWETSORGTOEFL CALL
  '/ 4/%&, WITHIN THE 53 53 4ERRITORIES OR #ANADA OR CALL THE 2EGIONAL 2EGISTRATION
#ENTER 22# THAT SERVICES THE COUNTRY WHERE YOU PLAN TO TEST 3EE THE Bulletin FOR )NTERNET BASED
TESTING FOR THE 22# CONTACT INFORMATION

#OMPLETING THIS FORM AND SUBMITTING PAYMENT WILL REGISTER YOU FOR 4/%&, )NTERNET BASED TESTING !LL
INFORMATION REQUESTED MUST BE COMPLETE OR YOUR FORM WILL BE RETURNED 4HIS FORM MUST BE RECEIVED AT
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v 0RINT ALL INFORMATION CLEARLY "E SURE TO ENTER v )F TESTING IN THE 53 53 4ERRITORIES
YOUR NAME EXACTLY AS IT IS SHOWN ON YOUR AND #ANADA MAIL THE COMPLETED FORM AND
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v 5SE BLACK INK %43 4/%&, I"4 2EGISTRATION /FFICE


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v )F YOU ARE TESTING OUTSIDE THE 53 0RINCETON .*   53!
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TEST 3EE THE "ULLETIN FOR )NTERNET BASED IS ON PAGE  OF THE "ULLETIN FOR )NTERNET
TESTING FOR THE 22# ADDRESSES BASED TESTING &OR OTHER INFORMATION USE
ONE OF THE COMMUNICATION METHODS LISTED
!MERICAN 3AMOA 'UAM 0UERTO 2ICO ON PAGE  OF THE "ULLETIN OR GO TO
AND 53 6IRGIN )SLANDS WWWETSORGDISABILITY

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#OPYRIGHT Ú  BY %DUCATIONAL 4ESTING 3ERVICE !LL RIGHTS RESERVED %$5#!4)/.!, 4%34).' 3%26)#% %43
THE %43 LOGOS AND 4/%&, ARE REGISTERED TRADEMARKS OF %DUCATIONAL 4ESTING 3ERVICE /THER PRODUCTS AND SERVICES
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!LL REQUIRED FIELDS MUST BE COMPLETED OR YOUR FORM WILL BE RETURNED 2EQUIRED FIELDS ARE NOTED WITH AN
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&IRST 'IVEN .AME AS ON PHOTO )$ 

,AST &AMILY3URNAME .AME AS ON PHOTO )$ 

-IDDLE .AME OR -IDDLE )NITIAL AS ON PHOTO )$ 

!DDRESS ,INE 

!DDRESS ,INE 

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#ITY

3TATE OR 0ROVINCE :IP OR 0OSTAL #ODE

#OUNTRY .ATIVE #OUNTRY #ODE REFER TO "ULLETIN 

'ENDER $ATE OF "IRTH .ATIVE ,ANGUAGE #ODE REFER TO "ULLETIN 


-ALE &EMALE -ONTH $AY 9EAR

.UMBER ON )DENTIFICATION $OCUMENT

#OUNTRY ,ISTED ON )DENTIFICATION $OCUMENT

0RIMARY 0HONE .UMBER INCLUDE AREA CODE COUNTRY CODE OR CITY CODE 

3ECONDARY 0HONE .UMBER INCLUDE AREA CODE COUNTRY CODE OR CITY CODE 

% MAIL !DDRESS

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4%34 ,/#!4)/.
#HOOSE TWO TEST LOCATIONS IN ORDER OF PREFERENCE %NTER THE CITY CODE AND PRINT THE CITY NAME AND
COUNTRY NAME FOR EACH CHOICE &OR TEST CENTER CODES AND LOCATIONS SEE THE I"4 4EST ,OCATION ,IST ON
THE 4/%&, 7EB SITE AT WWWETSORGTOEFL OR THE )NFORMATION AND 2EGISTRATION "ULLETIN FOR )NTERNET
BASED TESTING

&IRST #HOICE #ITY #ODE #ITY .AME

#OUNTRY .AME

3ECOND #HOICE #ITY #ODE #ITY .AME

#OUNTRY .AME

4%34 $!4%
3PECIFY FIVE TEST DATES IN ORDER OF PREFERENCE &OR TESTING DATES AND LOCATIONS SEE THE 4EST ,OCATION ,IST
ON THE 4/%&, 7EB SITE AT WWWETSORGTOEFL OR THE )NFORMATION AND 2EGISTRATION "ULLETIN FOR )NTERNET
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4HIS FORM MUST BE RECEIVED AT %43 AT LEAST FOUR WEEKS BEFORE YOUR REQUESTED FIRST CHOICE TEST DATE

-- -ONTH OF THE 9EAR $$ $AY OF THE -ONTH 99 9EAR
-- $$ 99 -- $$ 99 -- $$ 99
&IRST #HOICE 4HIRD #HOICE &IFTH #HOICE

-- $$ 99 -- $$ 99
3ECOND #HOICE &OURTH #HOICE

)F YOUR REQUESTED TEST DATES CANNOT BE ACCOMMODATED YOU WILL BE SCHEDULED FOR THE NEXT AVAILABLE
TEST DATE UNLESS YOU CHECK THE BOX BELOW
$O NOT RESCHEDULE ME PLEASE RETURN MY PAYMENT

3#/2% 2%0/24 2%#)0)%.43


5SING THE )NSTITUTION AND $EPARTMENT #ODE LISTS ON THE 4/%&, 7EB SITE AT WWWETSORGTOEFL INDICATE
WHERE YOU WOULD LIKE YOUR SCORE REPORTS SENT 4HE $EPARTMENT #ODE LIST IS ALSO IN THE "ULLETIN %NTER
A DEPARTMENT CODE ONLY IF YOU ARE APPLYING FOR GRADUATE STUDY )F YOU ARE NOT APPLYING FOR GRADUATE
STUDY YOU MUST FILL IN  AS THE DEPARTMENT CODE FOR EACH INSTITUTION OR AGENCY YOU LIST
)NSTITUTION $EPARTMENT )NSTITUTION $EPARTMENT
 3CORE 2EPORT 2ECIPIENT  3CORE 2EPORT 2ECIPIENT

)NSTITUTION $EPARTMENT )NSTITUTION $EPARTMENT


 3CORE 2EPORT 2ECIPIENT  3CORE 2EPORT 2ECIPIENT

0AGE  OF 
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4%34 &%%3
)NFORMATION ABOUT PAYMENT POLICIES IS IN THE "ULLETIN FOR )NTERNET BASED TESTING &EES ARE SUBJECT TO
CHANGE WITHOUT NOTICE

4/%&, I"4 TEST  53

!DD TAXES WHERE APPLICABLE  ???????

)N #ANADA ADD '34(34 AND 134 TO TOTAL REMITTANCE


'34(34 2EG  24  ???????
134 2EG   ???????

4/4!, !-/5.4 /& #(%#+ /2 -/.%9 /2$%2 %.#,/3%$  ???????

$/ ./4 3%.$ #!3( 4HERE IS A 53 FEE FOR RETURNED CHECKS

&OR ALL CHECKS DRAWN ON A 53 BANK ACCOUNT BE AWARE THAT YOU ARE AUTHORIZING %43 AT ITS DISCRETION
TO USE THE INFORMATION ON YOUR CHECK TO MAKE A ONE TIME ELECTRONIC DEBIT FROM YOUR ACCOUNT FOR THE
AMOUNT OF YOUR CHECK NO ADDITIONAL AMOUNT WILL BE ADDED )F YOU DO NOT HAVE SUFFICIENT FUNDS IN YOUR
ACCOUNT AN ADDITIONAL SERVICE FEE OF 53 WILL BE DEBITED ELECTRONICALLY FROM YOUR ACCOUNT

0LEASE WRITE $/ ./4 02).4 THE FOLLOWING STATEMENT AND SIGN YOUR NAME

) HEREBY AGREE TO THE CONDITIONS SET FORTH IN THE n )NFORMATION AND 2EGISTRATION "ULLETIN FOR
)NTERNET BASED TESTING RELATED TO THE TEST ADMINISTRATION FEE PAYMENTS SCORE REPORTING AND THE
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AND ADDRESS APPEAR ON THIS FORM

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Signature : ___________________________________________________ Date: ________________________

4HANK YOU FOR REGISTERING TO TAKE THE 4/%&, I"4 )F YOU HAVE PROVIDED AN E MAIL ADDRESS CONFIRMATION
OF THIS REGISTRATION WILL BE SENT TO YOUR E MAIL ADDRESS )F YOU HAVE NOT PROVIDED AN E MAIL ADDRESS
CONFIRMATION WILL BE SENT VIA THE 0OSTAL SERVICE

0AGE  OF 

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