Assessments for Educational, Clinical and Psychological Use

Test User's Qualification Form

Customers ordering assessments must have qualifications on file with Pearson. If this is your first order, please verify your qualification level for this and future purchases by filling out and sending this qualification form.

The qualification form takes 48 business hours to process. Upon completion, a catalog will be sent to you. If you need to place an order prior to the 48-hour processing time, please call 800-627-7271, ext. 3225 to place your qualifications over the phone.

* indicates required fields

* 1. Account Setup - Choose one of the following:
Establish a new account for me Add me to an existing account
If you chose "Add me to an existing account," enter account no. (if known)
* Organization Name (for personal account, enter "self")
* 2. Contact Information

* Name
* Prefix	Dr. Mr. Mrs. Ms.
* Title
* Telephone	Fax
* Email
* County
* School District (if applicable)
* Address
* City	* State * Zip
* Country

* 3. Primary Work Setting

4. Valid license or certificate issued by a state regulatory board: For example, LP, LPC, LCSW or other.
* Certificate/License Number
* License Type
* Certifying or Licensing Agency
* State * Expiration Date
5. Highest professional degree attained:
* Year * Institution
* Degree * Major Field
6. Course Work Completed in Tests & Measurements:
* You must choose Yes or No:Yes, completed coursework No, didn't complete coursework
* If yes Course Date
* If yes Institution
Graduate level Undergraduate level
7. Participation in related Pearson-approved workshop:
Workshop Name
Date Location
Leader
* 8. Qualification Level you are requesting:
description of qualification levels and requirements
9. Please list tests you use on a regular basis:

10. If you have any questions or comments, list them in the following area:

I Agree that: I am qualified to properly use any Pearson products I order, and I have provided Pearson with only accurate and true qualification information. Any Pearson test products purchased under my account will be used by me and/or under my supervision. Any Pearson test products purchased under my account will be used in accordance with all applicable legal and ethical guidelines. I have read and hereby apply Pearson's terms and conditions to all orders for my account and will abide by the Pearson terms and conditions and Qualification Criteria web pages.

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

Early Childhood - K12 - Psychology - Speech & Language - Medical
Home - News - Products A to Z - Ordering - Resources - Scoring - Support - Contact

		Customer Relations: 800-627-7271 (7 AM-6 PM CST) International Distributors pearsonassessments@pearson.com
	Copyright © 2008 Pearson Education, Inc. or its affiliates. All rights reserved. Trademarks \| Disclaimer \| Privacy Policy \| HIPAA Regulations and FAQ's