License Agreement Application for the SCL-90-R^®, BSI^® & BSI 18 Assessments

Complete this application if you are interested in obtaining permission to use the SCL-90-R, BSI or BSI 18 test in a research project and the project involves utilizing the test in a different manner than our standard catalog offering (i.e.: reproductions, translations, etc.). The cost for this permission will be determined based on the number of total test usages your study requires. However, there is a minimum $2500 license fee. There are no discounts available for this type of permission. (The approximate cost, per usage, is $3.30). All licenses are issued at the sole discretion of Pearson Assessments. Filling out this form does not guarantee that you will be granted a research license.

A license agreement is a legal document based on your request and will outline the special permission to use the test for a specified time period and project, based on the information you provide below. We require you to submit the complete application for review. Once the information is submitted and Pearson has decided whether a license will be offered, we will notify you and quote the approximate license fee. Then please allow 45 days to receive a license for your requested use of the test.

If you have questions about this process, please click here to review Frequently Asked Questions.

* indicates required fields

Choose the Test(s) for Which You Are Requesting Permission
*Name of Test:	SCL-90-R BSI BSI 18
Organization Information
*Organization Name: (This is who will be named as the licensee and must be the full legal entity name, e.g. XYZ, Inc., XYZ State University, etc.)
*State of Incorporation/Registration of Legal Entity: (e.g., a Delaware Corporation, a Minnesota Educational Institution, etc.)
*Org. Address:
*Org. City:
*Org. State:	*Org. Zip:
Org. Province: Canadian customers
Contact Information
*Contact Name:
*Contact Telephone:
*Contact Email:
Principal Investigator: (If different from contact person. This person will be named in the agreement to sign for permission)
Investigator Telephone:
Investigator Email:
Billing Information
Billing Address: (If different from organization address)
Billing City:
Billing State:	Billing Zip:
Billing Province: Canadian customers
Study Details
*Full Study Name:
*Study Begins:	*Study Ends:

I am requesting permission to do the following (check all that apply):
Reproduce - paper copy (photocopying answer sheets is prohibited) Reproduce - audio Reproduce - on-line web administration
Reproduce - on-screen local administration Other Please describe: Translate List language(s): (English & Spanish versions of the tests are available for licensing. Pearson cannot make previously translated non-commercial versions available. If your request involves a translation not available in the catalog, you must perform the translation within the guidelines set forth by the License Agreement.)

Methodology

	* Total number of test usages requested. If applicable, include re-administrations in the total number of usages. If more than one language, include number of usages per language.
* Method of Administration. Include information about how the test will be administered to subjects. (E.g., Paper and Pencil, On-screen, ACASI, etc. If on-line administration, list Web site and detailed information about security measures, etc.)

* Site Location(s). Include total number of sites involved in the administration of the test and include individual physical address of all sites. (If sites are TBD please note as such).

* Method of Data Collection. Include method in which data is gathered from the site(s) and transferred for scoring. (e.g. Transmitted via the Internet, Export file attached to e-mail, other)

* Method of Scoring. Name scoring method (e.g. Hand score, Q Local™, Statistical Scoring package such as SAS/SPSS) if applicable.

* Scoring Location Address.

Briefly describe the nature of the special permission that is required to carry out your study (i.e.: reasons why you are not simply purchasing standard catalog materials of the test � i.e.: answer sheets and scoring software). (It is not necessary to repeat information provided above.)

Please write any additional questions or comments in the following area:

IMPORTANT NOTE: This license application is subject to review by the appropriate Pearson Assessments representatives. Once reviewed, you will be contacted regarding the status of your application and the cost for the permission and use of the test(s). There is a standard, minimum license agreement fee of $2500 dollars. The final fee will be determined based on the number of test administrations. You will be required, as part of the license, to submit a report of your total number of test administrations upon the completion of your study. If your test usage exceeds the number of test administrations you requested, an additional fee will apply. Pearson Assessment test material is protected by copyright. A license is required to do most, if not all, of the activities described above. Such activity without a license from the copyright holder likely constitutes copyright infringement. All licenses are issued at the sole discretion of Pearson Assessments. Filling out this form does not guarantee that you will be granted a research license.

To Reach a Client Relations Representative

Call: 1-800-627-7271
7 AM-6 PM CST
Fax: 1-800-632-9011 or 952-681-3299
E-Mail: pearsonassessments@pearson.com

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License Agreement Application for the SCL-90-R®, BSI® & BSI 18 Assessments

Choose the Test(s) for Which You Are Requesting Permission

Organization Information

Contact Information

Billing Information

Study Details

Methodology

License Agreement Application for the SCL-90-R^®, BSI^® & BSI 18 Assessments