QUALIFICATION FORM
If you are ordering assessment instruments or tests and have not
already qualified as a test user, please complete and return this form.
Fax toll-free to: (866) 804-4843
Mail to:
PRP Qualifications
PO Box 3197
Sarasota, FL 34230-3197
or email to: cs.prpress@gmail.com
Please Print
Title (Dr., Ms., Mr.):_________
First Name:_____________________________________________
Last Name:_____________________________________________
Address:_______________________________________________
City-State-Zip:___________________________________________
Country:________________________________________________
Phone:__________________________ Fax:____________________
Email:____________________________
Highest Degree:___________ Major Field:____________________
* * * * * * * *
Diplomate of American Board of Professional Psychology (ABPP)?
Yes___ No___
In the National Register of Health Service Providers in Psychology?
Yes___ No___
If you answered YES to either of the questions above, no further
information is needed. Sign the certification below & return this
form.
* * * * * * * *
I am licensed as a _____________ in the state of _________________
License #_______________________ Exp. date__________________
Memberships (circle):
APA ACA NBCC NASW NASP Other:__________________________
If not licensed, please attach a separate list of courses, workshops, and
experience in the use of tests and instruments. Be sure and include
course/workshop content, institution where taken, and dates.
CERTIFICATION: I hereby certify that all of the information above
is accurate, agree to provide any other information requested by
Professional Resource Press (PRP), and grant permission for PRP to
contact any person or entity if they feel such contact might help them
determine my qualifications for the use of these instruments. I also
state that I believe I have relevant training to use these instruments
in an ethical and appropriate manner in accord with the Standards
for Educational and Psychological Testing, and that I assume full
responsibility for the proper use of all materials I order from PRP
(Refer to applicable ethical standards and go to:
Release and Photocopying of Testing Materials). I understand and
agree that PRP may refuse to sell me user qualified products
without further explanation and agree that PRP's decision is final.
Signature:_________________________________ Date:_______________
Students: A faculty member must also endorse the statement
above & agree to supervise your use of these instruments.
Professor's name:__________________________________________
Institution:________________________________________________
Professor's signature:________________________________________ Date:______________ ________________________________________________________
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