COPE Transfer Form  (Fee $30.00)

Print out and mail to: COPE Testing Ltd. 7B Pleasant Boulevard, Box 957, Toronto, Ontario, M4T 1K2
(Note: this is a mailing address only)

Family name:	Given names:
Title:                                  (Mr. / Mrs. / Ms. / Dr.)	Gender:                              (M/F)
Home telephone number (including area code):
Work telephone number (including area code):
Date of Birth:                                  /               /               (YYYY/MM/DD) year / month / day
E-mail address (if available):
Street Address:
Suite:	City:
Province:	Postal Code:

Please note that we will not accept a transfer after the Tuesday preceding the test.

Old Test Date:	New Test Date:
Registration Number:

Please send this form with a $30.00 cheque, money order or credit card details to the mailbox address at the top of this form. You will receive a new receipt for the new test.

Credit Card details: Expiry date ______________ (Month/Year)  Amount paid ______________

VISA []   MASTERCARD [] __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Name of Cardholder ______________________ Signature of Cardholder ______________________