Professional Resource Press
Test 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.

I am 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, 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. 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, 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