Professional Resource Press User Qualification Form

Title (Dr., Ms., Mr., etc.):_________ Name_________________________________________________________

Address:____________________________________________________________________________________

Address:____________________________________________________________________________________

City-State-Zip-Country_________________________________________________________________________

Phone_____________________ Ext_______ Fax___________________ Email____________________________

Highest Degree:_______________________ Major Field:______________________________________________

Are you a diplomate of the American Board of Professional Psychology (ABPP)?  Yes___ No___ Are You listed 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.

Licensed as a (profession)_______________________________________________________________________

in the state/province of________________ License #_________________________________ Exp. date_________

Memberships (circle all that apply):  APA   APS   ACA   NBCC   NASW   NASP   CPA  

Other (spell out association name):_________________________________________________________________

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 and that I meet the qualifications stated above for the use of these instruments. I also state that 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.

Signature:________________________________________________ Date:_______________________________

Students: A faculty member must also endorse the statement above, endorse your purchase, & agree to supervise your use of these instruments.

Professors' name and institution (PRINT):____________________________________________________________

Professors' signature:_______________________________________ Date:________________________________

Fax completed form to 941-343-9201, or mail to

PRP Qualifications, PO Box 15560, Sarasota, FL 34277-1560