Cambridge Distant IELTS Learning Programme  

(General Module)

Enrollment Form

(fill all necessary fields please)
.

Name: (according to your travel passport)

Address: 

 

Street address    

Suburb/Town   

City   

Postal code   

Country   

Phone: (Country code/area code/phone number

E-mail:

 Current level of English:

 

Beginning   Intermediate
Pre- Intermediate   Advanced

Intermediate

     
__________________________________________
5   7    
6   7.5    
6.5          
Necessary IELTS Overall Band Score
Age (for statistic purposes only) 

Payment details

I agree with course costs (US$ 695)

  

and Postal expenses

   

By Economy Post (US$ 40)

(delivered within 4 weeks)

or           By Air Post (US$ $45)

(delivered within 3 weeks)

or     By Express Post (US$ 85)

(delivered within 7-10 days)
Payment Options  

I choose the payment      

 

    by  Credit card

 

(Please include details of your credit card here or send them

 by fax 64-9-4880071)

Mastercard   

Visa   

Card number   

Expiry Date   

   

    by Telegraphic Transfer

 
   

(Account details will be sent in reply to this enrollment form)

(Optional)    

Preferable country to sit for IELTS exam:

Russia 

New Zealand 

If you choose New Zealand what services you need here (Tick)

Visitor Visa

Hotel booking

IELTS exam booking

IELTS preparation course booking

Individual training

  
 

 

 

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