DELTA ASSESSMENT REGISTRATION: INTEGRATED PROGRAMME

When completed, please email form to us at admin@thedistancedelta.com We will always

acknowledge receipt of your form by email, so if you do not hear from us please assume your
form did not arrive and send it again. The deadline for receipt of registration forms and
examination fees is Wednesday, 16th October. If we do not receive confirmation of payment by
this date we will be unable to enter you for assessment.

Personal Details

Please type your name in the form in which you would like it to appear on a certificate.

Full Name: Emily James

Date of Birth: 6th March 1971

Examination Centre Details

Name of Centre at which taking Module One Exam:

British Council Dar Es Salaam

Centre Number: TZ 003

Address of Centre at which taking Module One Exam:

Samora Avenue / Ohio Street

PO Box 9100

Tel: +255 222 165300 Email: Angela.Sangiwa@britishcouncil.or.tz

Name and Email address of Examination Officer

Name: Norah Ishengoma Email: norah.ishengoma@britishcouncil.or.tz

Confirmation of Attendance for Module One

I will be taking the Module One Exam on Wednesday 4th December 2013.

Date: Signature (type email address - this acts as electronic signature):

16/10/13 lellilove@hotmail.com

Confirmation of External Assessment for Module Two

I will be taking the Externally Assessed Assignment (LSA4) in (Please give month when you intend
to teach the lesson. Your LT should already be arranging this.):

Date (month): Signature (type email address – this acts as electronic signature):

Confirmation of Submission for Module Three

I will be submitting the Module Three Extended Assignment to my files (Final Extended
Assignment folder) by Sunday 8th December 2013.

Date: Signature (type email address - this acts as electronic signature):

16/10/13 lellilove@hotmail.com

Please see below for the payment information

Method of Payment

Cambridge Assessment fee for all three Delta Modules is £301.00

(i.e. £102 for Module One, £127 for Module Two and £72 for Module Three)

Please confirm the payment option which you are choosing by ticking one of the boxes:

1. I will make a debit / credit card payment through our secure online gateway -
instructions below. Please note this payment option is only open to those course
participants who filled out online application forms.

Log on to the website through the public pages: http://thedistancedelta.com

Under ‘Apply Online’ select the ‘Go to payments’ option

Click ‘Pay online’

Click ‘Pay’

Enter card details

 2. I will pay by debit /credit card (please phone or email us with the following card details):

Name / Type of Card:

Name on Card:
Card Number:
Expiry Date:
Security Code (last 3 digits on back of card):

3. I have sent a cheque (payable to International House Trust Ltd).

Postal address: Distance Delta Administrator, International House, 16 Stukeley Street,
Covent Garden, London WC2B 5LQ

Date sent:

4. My institute will pay the fees with a cheque / debit / credit card.

Contact email for institute payment:

5. yes I will pay by bank transfer. IMPORTANT: bank transfer is the slowest payment method.
It can take up to two weeks for the paperwork to come through to the bank and for us to
allocate payment to your account.

 You must label the transfer with your name and ‘the Distance Delta’
 You must email us to confirm and email / fax proof of payment i.e. a copy of your transfer
document

Without the above steps, we may not be able to register you with Cambridge in time.

I institute will pay the fees by bank transfer

Date of transfer: 11/10/13

Bank details
Allied Irish Bank, 10 Berkeley Square, London W1J 6AA

In GBP to:
Sort code: 23-83-97
Account number: 01572087
Account name: International House Trust Ltd
Swift code: AIBKGB2L
Iban number: GB78AIBK23839701572087