PDF《TOEFL? SCORE REINSTATEMENT REQUEST》

? ? ? ? TOEFL? SCORE REINSTATEMENT REQUEST FORM TOEFL? scores canceled by you can be reinstated if you submit this completed form to ETS with payment and it is received within

60 days after your test date.

The fee is US$20. Also, you can include up to

4 free score recipients. If you do not select score recipients at this time, you must pay US$20 per recipient to have scores sent at a later date. Please print clearly in all fields. To avoid delay, do not send a letter with this form. Scores will be reinstated and reported approximately

3 weeks after we receive your request and payment. Your scores will be provided to you and your designated score recipients shortly thereafter. NAME Last Name (Family or Surname) First Name (Given) EMAIL ADDRESS C You will receive a confirmation to this email address when this form is processed. TEST DATE (MM/DD/YY) TEST REGISTRATION NUMBER DATE OF BIRTH (MM/DD/YY) PHONE NUMBER Choose carefully. Score recipients, department codes and report codes listed on this form cannot be changed or canceled. ? See institution and department codes at www.ets.org/toefl/rpdt. The department code list is also printed in the Bulletin. Check code numbers for accuracy because requests are filled on the basis of code numbers you provide. Also, print the name of the institution, location and department. ? To designate an institution or fellowship not listed in the institution code list, provide the name and complete mailing address. If the designated score recipient is authorized to receive TOEFL scores, your request will be honored. ? If the designated score recipients included on this form are different than those previously selected during registration, your free score recipients will be updated to what is listed below. ? If you previously designated score recipients during registration and do not indicate any recipients below, your scores will be sent to the recipients previously selected. InstitutionCode Department Code SELECT UP TO

4 FREE SCORE RECIPIENTS ScorestoSend InstitutionorFellowship Sponsor Location(CityorCountry) Department M.I ? ? ? ? ? ? ? ? ? ?? TYPEOFCREDIT/DEBITCARD _ American _ Discover? _ JCB? Express? _ Visa? _ MasterCard? CREDIT/DEBIT CARD NUMBER Do not leave any spaces between numbers EXPIRATION DATE Month Year TOTAL ORDER AMOUNT REINSTATEMENT FEE: US$20 $ To pay online by credit/debit card, complete this form, print it, and fax it to 1+610―290-8972 To pay by check or money order (in US$ only), complete this form, print it, and mail it with payment to TOEFL Services C ETS PO Box

6151 Princeton, NJ 08541-6151 No refunds. If paying by certified check, money order or other physical payment, enclose your remittance payable to ETS-TOEFL. By sending your check to us, you authorize ETS to convert the check into an electronic fund transfer. Please be aware that your bank account may be debited as soon as the same day we received your payment and you will not receive a canceled check. Add Value Added or similar taxes where applicable. Visit the TOEFL website for information about taxes. By signing this form, I authorize ETS to release my TOEFL scores, under the conditions set forth in the Information and Registration Bulletin for the TOEFL iBT Test, to the score recipients I have designated on this form. Signature Date Copyright ?

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