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Checklist * DO NOT POST THIS PAGE

I have signed the Declaration on page 5.

I have provided 2 passport sized photographs (signed


on the back) on page 3. Photographs must the meet
requirements below:

Photographs must:

• be identical
• be no more than 6 months old
• be taken against a plain background so that features are clearly distinguishable
• be undamaged
• be in sharp focus and clear
• be print quality of professional standard
• be a close-up of the head and shoulders
• show the candidate looking straight at the camera
• show the candidate with a neutral expression
• show the candidate with mouth closed
• show the candidate with eyes open and clearly visible
• not show any shadows
• not show anything covering the face, the outlines of the eyes, nose or mouth

Please note that candidates must not wear glasses in photos submitted for
IELTS applications.

I have provided all the information required.

The cardholder has signed the Payment Form on page


6 (please note that your application will not be
processed if the payment is not successful).

I have attached a photocopy of my passport


(pages showing personal identification details and
expiry date).

• Post pages 3 - 6 to:

IELTS Melbourne
PO Box 16152
Collins St West VIC 8007

• Page 2 should be retained for your reference.

ALI81982 24/11/2010 12:00:21 PM 1


This notice has been written to help you.
Read it carefully and do as you are asked. If
there is anything you do not understand, ask
Notice to IELTS Candidates the IELTS Administrator or the examination
supervisor.
Disqualification warning
If you are caught infringing any of the candidate rules and regulations your test result will be
disqualified and notification sent to any receiving institution or professional body

Rules and Regulations


You must… · Notify the test invigilator immediately if test day
· Provide proof of your identity (e.g. passport or conditions in any way impede your performance.
national identity card) at registration and every
examination session. Second country nationals You must not…
must produce a passport. This ID must contain a · Impersonate another person or have another
number, a signature, a date of birth and a person impersonate you.
photograph. · Attempt to cheat, copy the work of another
· You acknowledge that photographs and biometric candidate or disrupt the test.
data (i.e. fingerprint data) will be obtained from · Use, or attempt to use, a dictionary, pager,
you on test days to assist in the confirmation of spell-checker, electronic recorder or mobile phone
your identity. In collecting and using your for the duration of the test. Any candidate doing
photographs and biometric data, the IELTS Test so will be disqualified.
Partners will comply with the Privacy Act 1988 · Talk to or disturb other candidates once the
(Cth) and the National Privacy Principles. examination has started.
· Provide two recent identical passport-sized · Smoke, eat or drink in the examination room.
photographs on registration. · Reproduce any part of the test in any
· Only have on your desk your identification, a format/medium. Any candidate doing so will have
pen/pencil and an eraser. their test results disqualified and be liable to
· Ensure mobile phones, pagers and any other prosecution.
electronic devices are switched off and placed · Remove any materials used during the
with personal belongings outside the test room. examination.
Any candidate who does not switch off their This includes, but is not limited to, examination
phone/pager, or who retains one in their papers, speaking task cards, answer papers and
possession, will be disqualified. working paper.

Advice and Information · Read carefully and follow the instructions printed
on the question paper and on the answer sheet.
Make sure you attend on time · Fill in the details required on the front of your
· Know the date, time and place of your question paper and on your answer sheet before
examination and arrive before the scheduled the start of the examination.
starting time.
· If you arrive late for any of the papers, report to Advice and assistance during the examination
the supervisor or invigilator. You may not be · If you are in doubt about what you should do,
allowed to take the examination. raise your hand to attract attention. An invigilator
will come to your assistance.
Provide what you need · You may not ask for, and will not be given, any
· Take into the examination room only the pens, explanation of the questions.
pencils and erasers which you need for the · If on the day of the examination you feel that
examination. your work may be affected by ill health or any
· Correction fluid and highlighters must not be other reason, you must inform the invigilator at
used. the time.
· Leave anything which you do not need, or which
is not allowed, outside the examination room. Leaving the examination room
· You may not lend anything to, or borrow anything · You may not leave the examination room without
from, another candidate during the examination. the permission of the supervisor or invigilator.
· Do not bring valuables as the test centre cannot · You cannot leave your seat until all papers have
be responsible for these. been collected and you have been told you can
leave.
Examination instructions · When you leave the examination room you must
· Listen to the supervisor and do what you are leave behind any paper used for rough work
asked to do. clearly crossed through and any other materials
· Tell the supervisor or invigilator at once if you provided for the examination.
think you have not been given the right question · Do not make any noise near the examination
paper or if the question paper is incomplete or room.
illegible.

Results · In exceptional circumstances, results may be


delayed and you may be required to re-take one
· Results are issued by test centres, usually 13 or more modules where the pattern of module
days after the test. results is highly unusual.
· Results may be delayed or withheld where any of · Please note that institutions and organisations
the Rules and Regulations have been breached. you have listed under question 24 may access
your results before you have received them by
mail.
*Important: please detach this page and retain for your own records .

ALI81982 24/11/2010 12:00:21 PM 2


Application form
please attach a recent please attach a second
passport-sized identical signed
photograph here securely passport-sized
(Note: the photograph photograph here using a
Please send to: must not be more paper clip
than 6 months old)
IELTS Melbourne
PO Box 16152
Collins St West VIC 8007

1. Preferred test date: 16/12/2010 Second choice: 11/12/2010


2. Family name: ALI
3. Title: Dr.
4. Other name(s): MOHAMED MAHMOUD MOHAMED
5: Address: 1062 Doncaster Rd
Doncaster East VIC 3109 Australia
6: Phone number: (+61) 03 98421475 / (+61) 0434962596
7. E-mail address: mmm@unimelb.edu.au
8. Date of birth: 15/01/1978
9. Gender: Male
10: Identity Document: Passport - 3081982
11. Country of origin: 057 - Egypt
12. First language: 005 - Arabic
13. Occupation (sector): 09 - Health and Social Services
(level): 3 - Employee (Senior level)
14. Why are you taking the test? 4 - For registration as a doctor
15. Which country are you applying/intending to go to? Australia
16. Which IELTS test format are you taking? Academic
17. Which IELTS test are you taking? Pen & Paper
18. Have you taken IELTS before? Yes
19. Most recent IELTS test details: 25/04/2009 - EG001 - Britich
council
20. Where are you currently studying English? Australia
21. What level of education have you completed? Post-graduate
22. How many years have you been studying English? 9 or more

For office use only

Scheme Test date

Date of payment Receipt number

ID checked Administrator initials

AC GT

ALI81982 24/11/2010 12:00:21 PM 3


Application form
23. Do you have any special needs due to ill health/medical condition? No

24. Would you like your results sent to any institutes? No

Institution Application
a) Name of person/department:
Name of institution/agency/body/employer:
File/case number:
Address:

b) Name of person/department:
Name of institution/agency/body/employer:
File/case number:
Address:

c) Name of person/department:
Name of institution/agency/body/employer:
File/case number:
Address:

d) Name of person/department:
Name of institution/agency/body/employer:
File/case number:
Address:

e) Name of person/department:
Name of institution/agency/body/employer:
File/case number:
Address:

ALI81982 24/11/2010 12:00:21 PM 4


Declaration
• I acknowledge that the IELTS test is jointly managed by British Council, IDP: IELTS Australia and Cambridge ESOL,
collectively referred to as the IELTS Test Partners.
• I certify that the information on this Application Form is complete, true and accurate.
• I understand that the personal data on this Application Form is collected for the purposes of the IELTS test, and I
consent for this data to be disclosed to, processed and stored by the IELTS Test Partners for the purpose of such
administration. I further consent for this data and my test result to be disclosed by the IELTS Test Partners to those
Recognising Organisations to which I apply, for the purpose of allowing these organisations to verify my test result or to
carry out enquiries in relation to suspected malpractice. If the IELTS Test Partners discover that a false or altered Test
Report Form has been provided to any of these Recognising Organisations I further consent that the IELTS Test Partners
may inform the same and provide them with my personal data and any relevant details relating to the work I produce as
part of my test taking.
• I understand that my personal data may be processed in an anonymous form for statistical and research purposes for
the development of Cambridge ESOL examinations. Cambridge ESOL and the centre administering the test confirm that
they will not disclose personal information about candidates to others except as stated in this Declaration or to the extent
permitted by law.
• I understand that I may view a copy of my personal data contained in the Application Form by contacting
ielts@cambridgeesol.org. I understand that a fee will be charged for access to this information.
• I understand that if the details on this form are not completed my application may not be processed. I further
understand that completing and submitting this Application Form does not guarantee enrolment on my preferred test
date or at my preferred test location. I understand that my enrolment will be confirmed in writing from the test centre.
• I acknowledge that I have read the IELTS Notice to Candidates contained on page 2 of this document and undertake to
abide by the rules and regulations contained therein.
• I understand that the IELTS Test Partners have a responsibility to all candidates and Recognising Organisations to
ensure the highest confidence in the accuracy and integrity of test results and that the IELTS Test Partners therefore
reserve the right to withhold test results temporarily or permanently, or to cancel test results which have been issued, if
they consider those results to be unreliable for reasons of suspected malpractice or any other irregularity in the test
process.
• I understand that my result may not be issued 13 days after the test if any of the IELTS Test Partners deem it
necessary to review any matter associated with my test, including making enquiries as to whether any rules or
regulations have been breached, as outlined in the IELTS Notice to Candidates. I understand that in exceptional
circumstances I may be required to re-take one or more IELTS components.
• I understand that if I engage in any form of malpractice, or do anything that might damage the integrity and security of
IELTS, I will not receive a test result, my test fee will not be refunded and I may be prohibited from taking the IELTS test
in the future. I understand that details of any malpractice that has been established or is being formally investigated may
be provided to the relevant Recognising Organisations, including visa processing authorities, and that suspected
malpractice will be reported centrally to the IELTS Test Partners and to any relevant test centre by the centre where the
suspected malpractice occurred.
• I understand that if any other person attempts to take the IELTS test in my place (i.e. in place of the person whose
details appear on this form), both I and such person will be liable to prosecution. Details relating to the situation may be
provided to the relevant authorities, including visa processing authorities.
• I consent for photographs and biometric data to be obtained from me on test days to assist in the confirmation of my
identity. I understand that the IELTS Test Partners will securely store my photographs and biometric data while they are
being used by the IELTS Test Partners and that the IELTS Test Partners will destroy my photographs and biometric data
when they are no longer required by the IELTS Test Partners.
• I understand that the work I produce as part of the IELTS test remains the property of the IELTS Test Partners. Under
no circumstances will it be released to candidates or to institutions or organisations, except in the investigation of
suspected malpractice whereby the work I produce as part of the IELTS test may be provided to relevant authorities.
• I understand that my personal data may be processed in an anonymous form for statistical and research purposes for
the development of Cambridge ESOL examinations. Cambridge ESOL and the centre administering the test confirm that
they will not disclose personal information about candidates, including images and biometric data, to others except as
stated in this Declaration or to the extent permitted or required by law.
• I agree that an observer may attend my Speaking test as part of the monitoring process.
• I understand that I will be charged the full test fee if I cancel my test or request a transfer within five weeks of the test
date, unless I provide appropriate medical evidence, within five days of the test date, to support the cancellation or
transfer.
• I acknowledge that I have read the IELTS Information for Candidates booklet.

Disclaimer: The International English Language Testing System (IELTS) is designed to be one of many factors used by
academic institutions, government agencies, professional bodies and employers in determining whether a test taker can
be admitted as a student or be considered for employment or for citizenship purposes. IELTS is not designed to be the
sole method of determining admission or employment for the test taker. IELTS is made available worldwide to all
persons, regardless of age, gender, race, nationality or religion, but it is not recommended to persons under 16 years of
age.

British Council, IDP: IELTS Australia and Cambridge ESOL and any other party involved in creating, producing, or
delivering IELTS shall not be liable for any direct, incidental, consequential, indirect, special, punitive, or similar damages
arising out of access to, use of, acceptance by, or interpretation of the results by any third party, or any errors or
omissions in the content thereof.

Signature Date

ALI81982 24/11/2010 12:00:21 PM 5


Payment form
Candidate name: ALI

Other name(s): MOHAMED MAHMOUD MOHAMED

Test fee: Registration or licensing for a particular occupation


($317 GST-free)

Card type: Mastercard

Card number: 5217-2952-0136-5958

CVV: 204

Expiry date: 02/2013

Payment Authority

I, the Cardholder, authorise IELTS Australia Pty Ltd to charge my credit card as
listed above on behalf of the above IELTS test candidate ("Candidate") for the
purpose of the Candidate registering to undertake the IELTS test. I acknowledge
that this Payment Authority will result in a Test Fee, of the amount shown above,
being charged to my credit card as identified above and that this charge will appear
on my credit card statement as a payment to IELTS Australia Pty Ltd.

Cardholder's name: Mohamed M Ali

Cardholder's
Signature:

Date:

Cardholder's e-mail address: mmm@unimelb.edu.au

ALI81982 24/11/2010 12:00:21 PM 6

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