COPE Identification Statement

Print out form, fill in information and attach photos. Mail in Section A. Keep Section B to bring to the Test.

Section A (for COPE Testing Ltd.)

Family name:	Given names:
Date of Birth:                                 /               /               / (YYYY/MM/DD)
Date of Test:	Signature of Candidate:
Home Phone Number:	Email:
Credit Card details: Expiry date ______________ (Month/Year)  Amount paid ______________ VISA []   MASTERCARD [] __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Name of Cardholder ______________________ Signature of Cardholder ______________________
The following declaration must be made by a Canadian citizen who has professional status (e.g.teacher, principal, doctor, lawyer, manager) and who is not a relative.
I,                                                    certify that this photograph is a true likeness of
(name of witness above)		(name of candidate above)
Signature of witness (please sign across photograph):  Profession                                     Business Telephone		Affix passport size  photo here

Section B (bring to the test with you)

Family name:	Affix passport size photo here
Given names:
Signature of Candidate:
Date of Birth:                                /               /             /

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